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CYCLOPEDIA 

OF 

OBSTETRICS  AND  GYNECOLOGY 

VOLUME  TWO 


A   PRACTICAL  TREATISE 


ON 


OBSTETRICS 

BY 

DR.   A.   CHARPENTIER 

ADJUNCT   PROFESSOR   AT   THE    FACULTY    OF   MEDICINE,    PARIS 

^n  fonv  Dolumes 

VOLUME  IL— THE  PATHOLOGY  OF  PREGNANCY. 

WITH  TWO  COLORED    PLATES  AND   45  FINE  WOOD   ENGRAVINGS 

TRANSLATED    UNDER  THE   SUPERVISION    OF,    AND    WITH    NOTES    AND    ADDITIONS    BY 

EGBERT  H.  GRANDIN,  M.D. 

OBSTETRIC    SURGEON    TO    THE    NEW    YORK;    MATERNITY    HOSPITAL;      INSTRUCTOR     IN      GYNECOLOGY 
AT     THE   NEW   YORK    POLYCLINIC  ;     FELLOW    OF    THE     OBSTETRICAL    SOCIETY,     ETC. 


NEW  YORK 
WILLIAM  V/OOD  &  COMPANY 

1887 


Copyright,  1887. 
WILLIAM  WOOD  &  COMPANY. 


The  Publishers'  Printing  Company 

157  AND  159  William  Street 

New  York 


coj^tents  of  volume  il 


CHAPTER  I. 


Epidemic  diseases  ;  colic ;  cholera;  intermittent  fever ;  eruptive  fevers  ;  typhoid 
fever  ;  sporadic  diseases  ;  pneumonia  ;  pleurisy  ;  tuberculosis  ;  icterus  ; 
syphillis  ;  lead  poisoning  ;  tobacco  poison ;  liysteria  ;  epilepsy  ;  trauma- 
tism ;  goitre  ;  erosions  of  the  cervix, pages  3-35 

CHAPTER  n. 

Lesions  of  the  digestion,  the  respiration,  the  circulation  ;  varices,  ascites,  edema, 
pernicious  anemia  :  lesions  of  the  secretions  and  of  the  excretions  ;  ptyalism, 
retention  of  urine,  cystitis  ;  albuminuria;  eclampsia;  puerperal  convulsions; 
neuralgias  ;  paralyses  ;  intellectual  disorders  ;  diseases  of  the  skin  ;  lesions  of 
the  pelvic  joints ;  puerperal  rheumatism,  muscular  and  articular ;  chorea  ; 
diseases  of  the  vulva  and  vagina  ;  abdominal  and  uterine  pains  ;  displacements 
and  distortions  of  the  uterus, pages  37-215 

CHAPTER  in. 

Diseases  of  tlie  ovum,  the  decidua,  placenta,  amnion,         .        .         pages  216-283 

CHAPTER  IV. 

Diseases  of  the  foetus  ;  fevers  ;  inflammatory  affections  of  the  various  organs  ;  dis- 
turbances in  the  circulatory  system ;  diseases  of  the  bones ;  congenital 
syphilis  ;  de?.th  of  the  foetus  and  consecutive  changes,  .        pages  284-310 

CHAPTER  V. 

Miscarriage  ;  its  causes,  phenomena,  prevention  and  treatment,     .  pages  311-349 

CHAPTER  VI. 
Extra-uterine  pregnancy,       ,        .  ■ pages  850-381 


PART  Y. 


The  Pathology  of  Pregnancy, 


CHAPTEE    I. 

DISEASES    AFFECTIXa     THE     PEEGl^ANT    WOMAN,     INDE- 
PENDENTLY  OF   THE   GRAVID   STATE. 

rpHE  gravida  may  be  affected  by  any  disease  whatsoever,  as  well  medi- 
-^  eal  as  surgical.  We  will  briefly  pass  these  diseases  in  review,  and 
note  the  reciprocal  action  which  they  and  pregnancy  have  on  one  another. 
Pregnancy,  indeed,  does  not  protect  women  from  any  disease,  absolutely, 
and  epidemic  diseases,  whether  essentially  so,  or  sporadic,  attack,  without 
distinction,  the  gravid  and  the  non-gravid. 

Epidemic  Diseases. 

Epidemic  Colic  (Grippe). 

Jacquemier,  in  1837,  found  that  this  affection  attacked  nearly  all  the 
women  in  the  Maternite.  He  did  not,  however,  find,  as  Cazeaux  did, 
that  it  was  more  fatal  in  them  than  in  non-gravid  women.  Cazeaux, 
however,  noted  a  large  number  of  miscarriages,  either  the  direct  conse- 
quences of  the  disease,  or  of  the  violent  cramps  from  which  the  women 
suffered. 

Cholera. 

The  Influence  of  Pregnancy  on  Cholera. — Bouchut  was  the  first  to  show 
that  pregnancy  has  no  influence  on  the  appearance  of  cholera,  in  that  it 
neither  protects  from,  nor  does  it  predispose  to  it,  and  that  cholera  follows 
its  usual  course  without  any  modification,  Avith  its  usual  variations  in 
character  and  severity.  This  does  not  apply  to  the  influence  of  cholera 
upon  pregnancy,  the  duration  of  which  is  usually  shortened. 

Frequency. — Among  upwards  of  8000  cases  of  cholera,  reported  by  dif- 
ferent observers,  139  occurred  in  pregnant  females,  of  whom  55  died. 

Age.  — A  ccording  to  Henning,  the  greatest  number  of  cases  have  occurred 
between  the  ages  of  twenty-one  and  thirty- five;  this  is  also  the  period 
during  which  the  mortality  has  been  the  most  considerable.  It  also  in- 
creases with  the  number  of  pregnancies. 

Time  of  Appearance. — According  to  Dietl  and  Hennig,  women  are 
most  liable  to  contract  cholera  during  the  latter  half  of  pregnancy. 
Among  63  cases  observed  by  Hennig,  there  were  33  deaths.  The  aver- 
age duration  of  the  disease  was  eight  days,  the  majority  of  the  deaths  oc- 
curring on  the  third  day.  He  states  that  the  malady  presents  the  usual 
four  stages,  viz.,  the  period  of  incubation,  of  diarrhoea  and  convulsions. 


4  A    TREATISE    OlST    OBSTETRICS. 

that  of  collapse,  and  tliat  of  reaction.  Thq  liemorrliages  from  the  genital 
canal,  noted  in  cases  of  pregnant  females,  have  been  attributed  by  Slav- 
jansky  to  a  special  form  of  endometritis. 

The  Influence  of  Cholera  on  Pregnancy. — Bonchnt  noted  the  occurrence 
of  abortion  in  one-half  of  the  cases  in  which  the  patients  survived  the  dis- 
ease. 

The  following  table  gives  statistics  from  various  sources  in  regard  to 
the  progress  of  labor: 


Eecoveries. 

Deaths, 

Bouchut, 

.     53  ( 

cases. 

\  Miscarriage 
(  None 

25 

27  - 

16 
6 

19 
21 

Saint  Eomes, 

.     10 

a 

J  Miscarriage 
(  None 

4 
6 

1 

3 
6 

Bourgeois,     . 

.       4 

le 

j  Miscarriage 
1  None 

3 

1 

1 

3 

Gendrin, 

.       3 

i< 

j  Miscarriage 
(  None 

1 
1 

1 
1 

Drasche, 

.     25 

i( 

j  Miscarriage 
(  None 

11 
14 

Hen  nig,    . 

.     30 

t .' 

j  Miscarriage 
\  None 

27 
12 

18 

2 

9 
10 

Hennig,  comparing  the  results  of  epidemics  in  Leipsic,  Vienna  and 
France,  found  that  about  fifty  per  cent,  of  the  pregnant  women  miscar- 
ried, the  average  mortality  being  forty-eight  per  cent. ,  while  of  those  who 
were  not  confined,  sixty-six  per  cent.  died. 

The  prognosis  for  both  child  and  mother  is  very  grave;  of  85  children 
50  died.  Authorities  differ  as  to  the  cause  of  death,  Bouchut  attributing 
it  to  the  mechanical  pressure  of  the  uterus,  due  to  the  strong  contractions 
of  the  abdominal  muscles,  others  to  lack  of  nourishment  on  the  part  of 
the  mother,  or  to  asphyxia,  while  Cazeaux  believes  that  the  change  in  the 
constitution  of  the  blood  (through  the  removal  of  the  serum)  leads  directly 
to  its  coagulation  in  the  placental  vessels,  with  a  consequent  arrest  of  the 
circulation.  The  prognosis  for  the  mother  is  no  more  favorable,  as  the 
statistics  before  quoted  prove.  Devilliers  proposes  the  induction  of  pre- 
mature labor  instead  of  waiting  until  it  occurs  spontaneously.  At  first 
sight  the  figures  seem  to  justify  this  interference,  but  Cazeaux  calls  at- 
tention to  the  wide  variations  in  the  severity  of  cholera,  so  that  in  the 
case  of  those  women  who  were  reported  to  have  died  without  aborting,  it 
terminated  fatally  before  this  accident  could  occur.  This  author,  as  well 
as  Baginsky,  disapproves  of  inducing  premature  labor,  but  Baginsky  ad- 
vises that  the  labor  be  terminated  if  it  has  once  begun.  Unfortunately, 
the  cholera  does  not  allow  time  for  interference  before  the  child  perishes. 

Has  Cholera  any  Influence  on  Delivery  f — If  Slavjansky  has  called  atten- 
tion to  the  hemorrhages  during  pregnancy,  they  do  not  appear  to  be  any 
more  frequent  after  delivery,  because  they  have  been  noted  only  two  or 


DISEASES    AFFECTING    PREGNANT    WOMEN.  0 

three  times  among  the  cases  observed.  Might  not  their  infrequency  be  ex- 
plained by  reference  to  the  changes  in  the  uterine  circulation  caused  by  the 
death  of  the  fffitus  ?  Drasche  has  reported  two  cases  of  eclampsia.  As 
regards  the  sequelae  of  labor,  they  do  not  seem  to  be  influenced  in  any  re- 
markable manner;  however,  Scanzoni  appears  to  admit  that  women  are 
more  predisposed  to  puerperal  fever.  Hennig  has  reported  two  cases  of 
peritonitis  and  parametritis  ;  both  were  cured.  The  treatment  is  the 
same  as  that  of  cholera  in  the  non-puerperal  state. 

Intermittent  Fever. 

Intermittent  fever  during  pregnancy  was  described  by  the  ancients,  and 
Jacquemier  quotes  from  Schurigius  a  case  in  which  a  woman,  pregnant 
for  the  third  time,  was,  in  the  second  month  of  pregnancy,  seized  with  a 
very  obstinate  quartan  fever.  In  the  last  month,  before  and  after  the 
paroxysm,  she  felt  the  fcetus  move,  quiver,  and  clearly  turn  about  from 
•one  side  to  the  other.  Finally,  after  a  violent  paroxysm,  she  was  delivered 
of  a  girl,  which  was  seized  at  the  same  hour  as  the  mother  with  very  vio- 
lent attacks  of  fever,  which  continued  during  seven  weeks.  Hoffmann 
and  Eussel  have  reported  similar  cases.  Bourgeois  described  a  case  of 
tertian  fever,  accom.panied  by  convulsive  movements  of  the  foetus  corre- 
sponding to  the  maternal  attacks,  a  fact  derived  from  Stokes.  Pitre 
Aubinais  observed  two  cases  of  intermittent  fever,  which  was  transmitted 
to  the  children,  so  that  they  were  born  with  enlarged  spleens,  and  showed 
attacks  of  tertian  ague,  corresponding  to  the  same  days  and  even  the 
same  hours  as  in  the  mother.  Frank  and  Joubert  have  seen  similar 
cases. 

Grenser  believes  that  there  are  forms  oO  intermittent  fever  that  bear  a 
certain  causal  relation  to  pregnancy.  If  that  were  true,  they  would  per- 
sist after  delivery,  whether  this  occurs  at  term  or  prematurely,  and  would 
then  disappear  spontaneously,  or  would  be  very  easily  cured,  while  inter- 
mittents  which  occur  in  women  advanced  in  their  pregnancy  rarely  disap- 
pear before  dJelivery  under  the  administration  of  quinine  or  other  reme- 
dies, and  in  all  cases  they  show  relapses.  But,  if  the  intermittent  fever 
does  stand  in  a  causal  relation  to  the  pregnancy,  the  attacks  recur  regularly 
after  delivery,  just  as  before,  without,  on  the  whole,  impeding  the  nor- 
mal progress  of  the  labor.  He  recommends  the  use  of  large  doses  of  sul- 
phate of  quinine.  Mendel  affirms  that  it  is  impossible  at  the  present  day 
to  admit  this  causal  relation  between  intermittent  fever  and  pregnancy, 
and  considers  it  as  rare.  Griesinger  insists  that  pregnant  women,  and 
especially  those  who  are  parturient,  are  perhaps  less  predisposed  to  inter- 
mittent fever  than  others,  and  cites  the  observations  of  Quadrat,  who 
noticed  at  Prague  only  two  cases  among  8,639  pregnant  or  puerperal 
women,  in  spite  of  the  prevalence  of  a  severe  epidemic.  Among  37,183 
women  observed  by  various  writers,  only  twenty  cases  were  reported : 


A    TREATISE    ON    OBSTETRICS. 


Frequency  of  Intermittent. 


Quadrat,     . 

8,639  cases. 

2  cases. 

Grenser, 

7,389     " 

1  case. 

Mendel, 

9,142     ■•' 

4  after  labor. 

Credo, 

594     '•• 

5     ''         " 

Strong, 

2,936     " 

t,  j  1  pregnant. 
/  1  after  labor. 

Br  u  mmerstiidt. 

816     " 

1  after  labor. 

Busch, 

6,077     ••' 

A  number  during  pregnancy. 

Mendel, 

.     1,115     •'■' 

2  during  pregnancy. 

Busch, 

.     1,114     '■' 

2      '\ 

Eitter, 

1,000     " 

Malaria,  14  cases  in  puerperium. 

Sachs,    ) 
Hirsch,  \     ' 

A  number  of  cases. 

Hubbard,    . 

1  case. 

Angt', 

1     " 

Eitter  admits  that  pregnancy  does  not  insure  immunity,  that  the 
malarial  cachexia  does  not  predispose  to  abortion,  and  that  the  intermit- 
tent fever  generally  assumes  an  acute  form.  This  acute  type  always  dis- 
apj)ears  for  a  short  time  during  the  act  of  delivery,  to  reappear  during 
the  first  three  weeks  of  convalescence.  It  would  seem  as  if  the  tendency 
of  the  latter  condition  was  to  arouse  the  acute  form  in  women  who  were 
the  subjects  of  the  chronic.  Finally,  according  to  him,  the  course  of 
the  acute  affection  is  not  regular^  and  the  remission  is  always  incomplete. 
Mendel  follows  Eitter  in  believing  that  intermittent  fever  is  rare,  even  in 
localities  in  which  it  is  indigenous.  Pregnancy  and  the  puerperal  condi- 
tion seem  to  predispose  to  it.  Although  tj^pical  intermittent  is  rare,  lar- 
val forms,  especially  neuralgic,  are  often  noted.  All  these  authorities 
agree  on  the  subject  of  treatment;  all  recommend  the  use  of  sulphate  of 
quinine  in  larger  or  smaller  doses.  Many  writers  have  inveighed  against 
the  administration  of  quinine  during  pregnancy,  because  of  the  supposed 
danger  of  producing  abortion,  but  Cazeaux  and  others  deny  that  the  drug 
is  harmful,  believing  that  the  general  disturbances  caused  by  the  attacks 
of  intermittent  are  far  more  likely  to  cause  the  premature  expulsion  of 
the  foetus  than  the  quinine.  Many  physicians,  who  have  had  a  large 
practice  in  malarial  districts,  have  never  had  cause  to  fear  the  action  of 
quinine  upon  pregnant  women.  It  is  not  only  an  innocuous  remedy,  but 
it  is  the  surest  preventive  when  abortion  is  rendered  imminent  by  the 
occurrence  of  the  fever.     (Cazeaux.) 

Spiegelberg  aflSrmsthat  intermittent  fever  is  rare  during  the  last  months 
of  pregnancy,  and  that  it  does  not  disturb  its  course.  Intermittent,  he 
thinks,  when  it  is  present  in  a  chronic  form,  assumes  its  acute  form,  or 
a  transient  acuteness,  during  pregnancy.  He  believes  strongly  in  full 
doses  of  sulphate  of  quinine,  although  this  drug  does  not  prevent  the  re- 
currences which  appear  during  the  first  three  months  after  delivery.  The-- 
disease  is  temporarily  arrested  during  delivery. 


DISEASES.  AFFECTING    PREGNANT   WOMEN.  7 

The  fever  which  appears  during  pregnancy  is  cliaracterized  by  the  ab- 
sence of  intermissions,  and  by  the  presence,  on  the  contrary,  of  a  con- 
tinned  febrile  condition,  interrupted  by  irregular  chills.  The  stage  of 
apyrexia  is  never  complete,  and  even  in  the  most  typical  cases  the  inter- 
mittence  is  never  regular  in  its  rhythm.  The  dose  of  sulphate  of  quinine 
should  be  increased  still  more  during  convalescence.  Playfair  calls  atten- 
tion to  the  transmission  from  the  mother  to  the  foetus;  and  the  frequency 
with  Avhich  hypertrophy  of  the  spleen  is  found  in  young  infants  in  mala- 
rial countries,  leads  him  to  infer  that  the  intra-uterine  affection  must  be 
common.  He  has  often  noted  this  fact  in  India,  without,  however,  having 
been  able  to  convince  himself  that  the  mothers  had  suffered  from  inter- 
mittent fever  during  their  pregnancy. 

Goth's  researches  differ  in  certain  respects  from  the  results  obtained  by 
Eitter.  In  the  course  of  six  years  he  observed  881  deliveries^  in  which 
46  women  were  attacked  by  malaria  during  pregnancy,  and  during  a 
period  more  or  less  extended  subsequently;  of  these  46,  only  27  went  to 
full  term,  19  being  delivered  prematurely. 

1  at  4  months.  2  at  5  months.  2  at  6  months. 

5  at  7      "  9  at  8    '^ 

In  41.3  per  cent,  of  the  cases,  then,  there  was  an  interruption  of  the 
pregnancy.  The  inference  from  these  statistics,  moreover,  is  that  the 
danger  increases  with  the  advancement  of  the  pregnancy,  premature  de- 
livery being  more  frequent  than  abortions.  He  agrees  with  Kaminski 
and  Runge  in  attributing  the  death  of  the  foetus  to  the  elevation  of  tem- 
perature in  the  mother  (106°  F.  and  above)  during  the  prolonged  attack, 
and  attaches  less  importance  to  the  maternal  angemia  consecutive  to  the 
disease,  and  to  the  direct  infection  of  the  foetus  by  the  malarial  poison. 
Goth  observed  that  pregnant  women,  after  the  second  or  third  attack, 
complained  of  lumbar  pains,  and  that  slight  uterine  contractions  could 
be  detected,  and  the  mortality  of  children  who  are  born  under  these  con- 
ditions is  much  higher  than  that  of  other  countries.  They  weigh  at  least 
eleven  ounces  less  than  others.  As  regards  the  labor,  he  has  noted 
irregularity  in  the  contractions,  feeble  pains,  especially  during  the  first 
stage,  until  the  cervix  is  completely  dilated;  this  stage  is  generally  twice 
as  long  as  in  ordinary  cases.  This  feebleness  in  the  contractions,  although 
less  evident,  is  also  present  during  the  expulsive  stage,  because  it  was 
necessary  to  interfere  more  frequently  in  those  cases  (forceps,  extraction  of 
the  placenta,  etc.) 

The  Influence  of  Labor  on  Malaria. — This  is  shown  in  every  instance  by 
the  arrest  of  the  attacks  (Ritter).  Goth,  on  the  contrary,  has  seen  some 
cases  in  which  the  attacks  were,  it  is  true,  reduced  to  the  number  of  one 
or  two,  but  they  reappeared  subsequently,  and  in  the  great  majority  of 
the  cases  the  attacks  recun'ed  after  delivery  with  the  same  regularity  as 


O  A   TREATISE    ON    OBSTETRICS. 

before.  During  convalescence  women  are  predisposed  to  it.  Ritter,  Goth 
and  Mendel  have  seen  women  aifected  after  confinement  who  were  free 
from  malaria  during  pregnancy.  Quinine  acts  in  the  same  way  after  con- 
finement. Goth  does  not  favor  maternal  nursing  in  these  cases;  it  may 
be  allowed  in  light,  but  not  in  severe  cases. 

Eeuptive  Fevers. 
8mall-pox. 

The  eruptive  fevers  seem  to  acquire  an  unusual  severity  in  preg- 
nant females,  and  small-pox  especially,  according  to  most  authors,  pro- 
duces abortion  and  subsequent  death  of  the  patients.  All  writers  agree 
regarding  the  exceptional  gravity  of  the  prognosis  of  small-pox  occurring 
in  a  pregnant  woman.  Cazeaux,  however,  has  already  made  an  important 
distinction  between  discrete  and  confluent  small-pox;  the  first  almost  al- 
ways terminating  in  a  cure,  even  when  the  pregnancy  is  interrupted;  the 
second,  which  is  so  serious  in  the  non-pregnant  state,  assuming,  during 
the  period  of  gestation,  a  peculiarly  grave  form.  Abortion  and  death 
would  then  be  the  rule,  almost  certainly.  With  Jobard,  we  think  it  neces- 
sary in  this  connection  to  distinguish  the  three  forms  of  small-pox:  1st. 
Varioloid;  2d.  Discrete  variola;  3d.   Confluent  variola. 

1st.  Varioloid. — Even  when  confluent  it  is  generally  benign,  and  only 
rarely  causes  abortion.  Mayer  has,  however,  reported  four  abortions 
among  37  cases  of  varioloid.  We,  ourselves,  have  observed  a  case  of  con- 
fluent varioloid  in  a  woman  six  months  pregnant.  The  mother  was  cured, 
the  pregnancy  pursued  its  course,  and  the  woman  was  delivered  at  term 
of  a  living  child  (the  fifth)  who  did  not  present  any  pock-marks,  and 
who  was  only  more  emaciated  than  this  patient's  other  children. 

2d.  Discrete  Variola. — Abortion  is  more  frequent  (Jobard  noted  four 
abortions  in  eight  cases),  but  recovery  of  the  mother  is  the  rule. 

3d.  Confluent  Variola. — Here,  on  the  contrary,  abortion  is  almost  in- 
variably the  rule,  and  the  death  of  the  mother  follows,  in  the  great  ma- 
jority of  the  cases,  during  the  days  immediately  succeeding  abortion;  the 
same  result  is  far  more  likely  to  occur  if  the  variola  assumes  the  hsemor- 
rhagic  form. 

This  opinion  is  now  held  by  all  authors,  but  they  still  differ  as  to  the 
period  at  which  the  abortion  occurs.  It  is  during  the  suppurative  stage 
that  this  accident  is  especially  seen  to  occur.  But  abortion  does  not  always 
take  place  under  the  same  conditions.  Sometimes,  in  short,  the  foetus  is 
expelled  dead,  sometimes  living,  and  the  conditions  are  evidently  all  differ- 
ent, so  that  the  causes  of  abortion  may  thus  be  multiplied.  As  soon  as 
the  condition  of  the  maternal  blood,  the  infectious  germ  of  the  disease, 
the  exaggerated  influence  of  the  maternal  temperature,  or  the  infection 
of  the  foetus  by  the  mother,   who  transmits  small-pox  to  it,  cause  the 


DISEASES    AFFECTING    PREGNANT    WOMEN.  9 

deatli  of  this  foetus,  abortion  will  become  inevitable;  because  this  foetus 
is  no  longer  anything  but  a  foreign  body,  of  Avliich  the  womb  will  inevi- 
tably tend  to  relieve  itself.  But  these  are  not  the  only  causes,  and  we 
must  take  into  account  another  phenomenon,  which  alone  may  explain  the 
frequent  abortion:  it  is  uterine  hemorrhage.  Spiegelberg  and  others 
refer  this  to  a  hemorrhagic  endometritis.  Brouardel  believes  that  the 
premature  contractions  of  the  uterus  are  due  to  an  excess  of  carbonic  acid 
in  the  blood. 

Does  pregnancy  predispose  women  to  contract  the  grave  forms  of  the 
disease  ?  With  Jobard,  we  think  not,  and  claim  that  it  is  by  reason  of 
the  pregnancy  itself,  and  of  the  abortion,  that  the  disease  assumes  a  form 
and  a  character  exceptionally  severe.  Brouardel  and  others  show  that,  in 
certain  cases  after  abortion,  small-pox  may  become  hemorrhagic.  Variola 
does  not  predispose  to  puerperal  septicsemia;  the  latter  is  a  serious  com- 
plication, which  hastens  the  fatal  termination.  Death  generally  occurs 
from  the  eleventh  to  the  fourteenth  day  of  the  disease,  often  before,  in 
hemorrhagic  small -pox. 

The  prognosis  is  exceedingly  grave,  as  Meyer  shows  in  a  series  of  tables, 
of  which  the  following  is  a  summary:  Of  29  pregnant  women,  5  or  17.2  pei' 
cent,  died,  9  or  31  per  cent,  aborting;  of  47,  in  another  series,  18  or  38.2 
per  cent,  died,  23  aborting.  The  mortality  was  greater  in  an  epidemic 
occurring  in  the  spring  and  summer. 

As  regards  the  foetus,  three  alternatives  may  present:  1st.  The  child 
may  die  in  the  mother's  womb;  2d.  It  may  be  born  alive,  and  then  it  is 
either  iu  good  condition  and  grows  up,  or  it  is  born  alive,  but  succumbs 
a  few  hours  or  days  after  birth;  3d.  Finally,  the  child  may  be  born 
with  small-pox  pustules. 

1st.  The  Child  dies  in  the  Mother's  Womb. — We  believe  with  Spiegel- 
berg and  others,  that  in  order  to  explain  this  death,  great  importance 
should  be  assigned  to  the  maternal  temperature,  and  that  if  hemorrhage 
plays  a  part,  it  is  a  secondary  part,  so  to  speak,  compared  with,  that  of 
temperature. 

2d.  The  Child  is  horn  Alive  and  Stirvives, — It  is  in  cases  of  varioloid, 
and  discrete  small-pox  especially,  that  the  foetus  escapes  the  danger.  But, 
if  a  certain  number  are  born  well,  the  majority,  as  we  have  observed,  are 
usually  born  feeble  and  emaciated,  which  accounts  for  their  mortality 
during  the  days  immediately  following  birth.  It  is  a  curious  fact  that 
these  infants  quite  frequently  resist  vaccine.  Burkhardt,  of  Bale,  re-vac- 
cinated 28  pregnant  women,  with  the  following  result:  In  4  women  at  the 
end  of  their  pregnancy,  vaccination  was  successful;  in  4  children  it  Avas 
unsuccessful,  one  child  resisting  it  for  six  months.  Vaccination  seems  in 
these  cases,  then,  to  affect  both  mother  and  child.  Hence  the  necessity 
of  re- vaccinating  all  pregnant  women.     If  vaccine  can  act  thus  on  the 


10  A    TREATISE    ON    OBSTETRICS. 

foetus  through  the  mother,  so  much  the  more  reason  should  there  be  why 
small-pox  should  be  transmitted  in  the  same  manner. 

3d.  Certain  infants  are  born  with  evident  marks  of  variola,  either  in 
the  shape  of  fully-developed  pustules,  or  cicatrices.  Many  cases  are  on 
record  in  which  children  were  born  with  small-pox,  while  the  mothers 
remained  uninfected;  in  one  instance  the  child  was  apparently  infected 
at  the  time  of  fecundation,  the  mother  remaining  well.  These  cases,  it 
must  be  acknowledged,  are  really  exceptions,  and  small-pox  in  the  foetus 
is  rare.  It  is  only  when  the  mother  is  infected  at  the  end  of  gestation 
that  this  has  been  verified;  and  then  the  foetus  comes  into  the  world  either 
dui'ing  the  period  of  invasion  (Gariel),  or  more  commonly  towards  the 
end  of  the  eruptive  stage,  or  at  the  time  of  the  suppurative  fever  (Chaig- 
neau  (Noblet  de  Rennes,  Legrand).  Before  the  ninth  month  cases  be- 
come more  and  more  rare,  while  towards  the  sixth  and  fifth  month  they 
are  almost  exceptional.  Male  infants  seem  to  be  more  predisposed,  to  it 
than  females. 

If  the  pustules  in  the  foetus  present  a  striking  resemblance  to  those  of 
the  adult,  they  have  not  the  same  distribution.  Aside  from  the  fact  that 
the  small-pox  is  usually  discrete,  the  pustules  are  scattered  in  an  irregu- 
lar manner,  and  are  not  most  numerous  on  the  face.  Nevertheless,  in 
some  cases  the  variola  has  been  confluent.  The  pustules  contain,  as  a 
rule,  a  yellowish  and  slightly  opaque,  but  rarely  purulent,  fluid.  How- 
ever, true  suppuration  has  been  noted.  Mother  and  child  may  be  at- 
tacked simultaneously;  the  small-pox  then  pursues  a  parallel  course  in 
the  two  subjects.  More  commonly,  however,  this  does  not  occur,  and 
the  small-pox  is  more  advanced  in  the  mother  than  in  the  foetus. 
Children  have  been  attacked  three  months  after  the  mother.  Some- 
times the  period  of  invasion  seems  to  be  indicated  by  a  peculiar  malaise, 
an  extreme  agitation  of  the  foetus,  followed  by  the  cessation  of  active 
movements. 

The  treatment  consists  in  re- vaccinating  all  pregnant  women,  because 
the  cases  reported  by  Burckhardt,  although  too  few  to  permit  the  drawing 
of  a  positive  conclusion,  prove,  at  least,  the  harmlessness  of  vaccination, 
as  regards  both  mother  and  child. 

Scarlet  Fever. 

Scarlet  fever,  although  not  absolutely  rare  among  the  complications  of 
labor,  appears  on  the  contrary  to  be  the  exception  during  pregnancy,  to 
judge  from  the  small  number  of  observations  reported  by  authors.  Ca- 
zeaux  never  saw  a  case;  Bourgeois,  however,  mentions  an  epidemic  ob- 
served in  Vienna  in  1801.  Scarlatina  assumes  a  grave,  malignant  type, 
and  terminates  in  abortion  in  the  case  of  every  woman,  in  death  in  the 
majority.  All  the  descriptions  of  writers  have  reference  to  scarlet  fever 
occurring  after  delivery.     A  single  observation  of  Bourgeois  seems,  how- 


DISEASES    AFFECTING    PREGNANT    WOMEN.  11 

ever,  to  have  related  to  a  case  of  scarlet  fever  which  occurred  during  the 
latter  days  of  pregnancy,  the  woman  dying  five  days  after  delivery. 

Measles. 

Measles  is  of  rare  occurrence  during  pregnancy,  for  only  twenty  or 
twenty-five  cases  at  the  most  can  be  collected  among  different  authorities. 
According  to  Levret,  it  equals  in  gravity  the  other  eruptive  fevers,  and  is 
almost  always  accompanied  by  abortions  and  premature  delivery.  Grisolle 
and  Cazeaux,  on  the  other  hand,  observed  two  cases  in  which  the  preg- 
nancy pursued  its  course.  Bourgeois  agrees  with  Levret.  Among  fif- 
teen cases  observed  by  him,  he  noted  eight  abortions  or  premature  births; 
of  the  eight  children,  five  were  non-viable  (born  before  seven  months), 
three  at  the  seventh  or  eighth  month.  In  women  who  were  only  between 
the  second  and  fifth  month  of  pregnancy,  the  disease  pursued  its  usual 
course,  but  it  became  more  severe  as  the  pregnancy  was  more  advanced. 
The  premonitory  symptoms  of  abortion  appeared  towards  the  end  of  the 
disease;  as  a  rule,  delivery  did  not  occur  until  from  one  to  three  days  later, 
and  sometimes  the  disease  had  terminated. 

When  women  were  attacked  with  the  disease  at  the  end  of  pregnancy, 
premature  delivery  took  place  at  the  outset,  accompanied  by  fever  and 
serious  symptoms.  The  foetus  was  dead-born,  or  perished  within  a  few 
hours  or  days  after  birth.  The  disease  pursued  its  course  and  the  women 
slowly  recovered.  In  rare  instances  the  children  were  born  with  measles. 
Bourgeois  saw  one  case,  the  infant  being  born  fifteen  days  before  full 
term  and  living  only  three  days.  Gautier  collected  eleven  cases,  in  six  of 
which  the  children  presented  the  morbillous  eruption. 

Measles  occurring  during  pregnancy,  therefore,  may  predispose  to  the 
death  of  the  foetus  and  to  abortion;  it  does  not  endanger  the  mother. 
The  prognosis  during  the  puerperal  state  is  less  grave. 

Erysipelas. 

Erysipelas,  like  the  other  eruptive  fevers,  may  attack  pregnant  females,, 
and  pregnancy  does  not  seem  to  offer  any  protection  from  it.  Facial  ery- 
sipelas, especially,  has  been  observed  several  times,  and  if  pregnancy  does 
not  seem  to  influence  the  course  of  the  affection,  the  case  is  not  the  same 
as  regards  the  influence  of  erysipelas  upon  pregnancy.  The  latter  is  often 
interrupted,  either  by  abortion  or  by  premature  delivery,  and  the  foetus. 
may  be  directly  affected  by  the  rise  of  temperature  in  the  mother.  The 
mother,  as  in  cases  of  small-pox,  may  die  or  be  cured;  everything  depends, 
on  the  severity  of  the  disease.  However,  erysipelas  seems  to  be  less  seri- 
ous than  variola,  and  may  be  placed  on  the  same  level  as  measles.  We 
have  only  seen  one  case:  the  woman,  who  Avas  attacked  at  about  the  fourth, 
month  of  pregnancy,  presented  until  term  (when  she  was  delivered  of  a, 
living  child)  a  series  of  erysipelatous  eruptions  of  the  face,  which  reap- 


12  A    TREATISE    ON    OBSTETRICS. 

peared  montli  after  month,  and  were  remarkable  by  reason  of  the  insig- 
nificance of  the  febrile  manifestations,  although  the  eruption  was  well 
marked. 

Ty'phoid  Fever. 

While  Eokitansky  and  Niemeyer  believe  that  pregnancy  insures  a  sort 
of  immunity  from  typhoid  fever,  others  regard  this  opinion  as  being  too 
positive,  and,  while  agreeing  in  the  belief  that  typhoid  is  more  common 
after  delivery  than  'X  is  during  pregnancy,  they  prove,  by  numerous  ob- 
servations (283),  that  typhoid  may  not  only  attack  pregnant  women,  but 
that  it  does  not  always  present  the  same  form — that  the  disease  may  as- 
sume the  abdominal,  exanthematic  or  recurrent  type.  These  three  vari- 
-eties,  moreover,  do  not  seem  to  manifest  either  the  same  frequency,  or  the 
same  severity,  the  exanthematic  and  recurrent  forms  having  been  most  often 
observed.  Typhoid  fever  may  attack  women  at  any  period  of  pregnancy; 
however,  it  occurs  more  frequently  during  the  first  than  during  the  last 
months.  But  the  three  types  of  the  disease  do  not  seem  to  possess  the 
same  gravity,  and  while  the  abdominal  variety  is  most  severe,  the  exan- 
thematic and  recurrent  would  seem  to  be  less  dangerous  to  women.  This 
danger  also,  according  to  Spiegelberg,  depends,  perhaps,  less  upon  the 
form  of  the  disease  than  it  does  upon  the  period  of  the  pregnahcy  at 
which  it  occurs,  and  upon  the  abortion  which  it  produces,  since  the  latter 
is  inevitably  followed  by  more  severe  hemorrhages  during  the  early  than 
during  the  later  months,  when  the  consequences  are  simply  those  of  a 
premature  delivery.  In  322  cases  the  foetus  was  expelled  prematurely  in 
182. 


Cases. 

Miscarriages. 

Prem.  Labor. 

r  re^  Hi; 
to  tai- 

Bourgeois, 

.     37 

12 

10 

ls 

Forget, 

.       4 

2 

2 

Grisolle, 

.       1 

i 

Mauriceau,    o 

,       3 

3 

Piorry 

,       2 

1 

1 

Wallichs, 

.       2 

1 

1 

Bartels, 

1 

1 

Kaminsky,     . 

.     87 

54 

33 

Murchison,    . 

.      14 

8 

1 

5 

Weber, 

.     63 

23 

40 

Duguyot, 

.     62 

40 

22 

Zuelzer, 

,     32 

22 

10 

Lehnerdt, 

.     14 

2 

J 

12 

322  182  140 

According  to  Zuelzer  and  Wardell,  exanthematic  typhoid  is  the  least 
:serious  of  all,  its  influence  on  pregnancy  being  almost  nil. 

Prognosis.  — This  is  extremely  grave  for  the  child,  since  not  only  does 
abortion  cause  its  death,  but  in  cases  of  premature  delivery  the  foetus  is 


DISEASES    AFFECTING    PREGNANT    WOMEN.  13 

often  clead-borii^  or,  if  it  is  born  alive,  it  freqnently  perishes  dnring  tlie 
days  sncceeding  its  birtli,  either  from  congenital  asthenia,  or  with  symp- 
toms of  typhoid  fever. 

What  is  the  true  cause  of  the  death  of  the  fcetns  ?  All  authors  agree 
in  attributing  it  to  the  elevation  of  the  mother's  temperature.  Kaminsky 
has  shown  that,  as  soon  as  the  maternal  temperature  rises  to  104°,  the 
fa?tal  heart-beat  is  observed  to  become  accelerated  in  proportion  to  the 
height  of  the  mother's  temperature,  and,  in  addition,  the  foetus  executes 
irregular  movements  at  107°  to  107.5°.  Foetal  death  is  inevitable,  but 
the  danger  begins  at  104°.  According  to  Kaminsky,  it  is  the  elevation 
of  the  maternal  temperature,  not  the  typhoid  infection,  which  alone 
causes  the  death  of  the  frotus;  its  expulsion  may  be  delayed  for  a  longer 
or  shorter  time  afterwards,  even  as  late  as  the  beginning  of  tiie  mother's 
convalescence. 

The  prognosis  as  regards  the  mother  is  more  favorable,  and,  like  Spie- 
gelberg,  Fiedler  believes  that  its  gravity  depends  much  more  upon  the 
abortion  and  consequent  hemorrhage  than  upon  the  disease  itself.  The 
influence  of  pregnancy  on  typhoid  fever  seems  to  be  obscure. 

Sporadic  Affections. 

Pneumonia. 

We  have  seen,  in  studying  the  changes  induced  in  the  body  by  preg- 
nancy, that  Kuchenmeister  and  others  have  proved  that  the  pulmonary- 
capacity  is  not  lessened  during  this  condition — that  if  the  thorax  is  not  so 
deep,  this  diminution  in  depth  is  compensated  for  by  the  increase  in 
breadth  of  the  base  of  the  chest,  and  that  after  delivery  the  chest  resumes 
its  usual  shape.  Pulmonary  diseases  during  pregnancy  react  seriously 
upon  the  woman's  health,  and  may  all  be  observed;  but,  aside  from  pul- 
monary congestions,  oedema,  and  hemorrhage,  it  is  the  acute  affection, 
pneumoniia,  which,  accordnig  to  all  authorities,  deserves  special  attention, 
both  on  account  of  the  grav^ity  which  it  impresses  upon  the  pregnancy, 
and  its  influence  on  gestation. 

Etiology  and  Frequer.cy. — Pneumonia  during  pregnancy,  as  well  as  in 
the  non-pi-egnant  stage,  is  due  to  a  chill,  and  consequently  it  may  occur 
without  distinction  at  any  period  of  this  pregnancy;  only  pregnant  women, 
according  to  Eieau  and  Devilliers,  are  predisposed  to  it  by  reason  of  the 
changes  which  ]3regnancy  causes  in  the  composition  of  the  blood,  especi- 
ally the  excess  6f  fibrin.  Statistics  presented  by  authorities  correspond 
in  fact  to  every  period  of  pregnancy,  and  the  important  fact  deduced 
from  these  observations  is  that  pneumonia  almost  certainly  causes  abor- 
tion, and  that  a  considerable  number  of  women  die.  Bourgeois  observed 
twelve  cases,  with  eight  abortions  and  as  many  deaths;  Grisolle  reports 
only  one  recovery  out  of  fifteen  cases,  six  women  being  delivered  at  term. 


14  A    TREATISE    OW    OBSTETRICS. 

wliile  tlie  other  nine  miscarried.  Wernicli  thinks  that  cardiac  failure  is 
the  principal  danger  in  cases  of  pneumonia  during  pregnancy.  The 
weakened  action  of  the  right  ventricle  leads  to  stasis  of  the  pulmonary 
circulation,  and  consequent  emptying  of  the  left  ventricle.  If  the  pneu- 
monia is  extensive,  as  the  vis  a  tergo  becomes  diminished  on  one  side  (the 
left  ventricle),  while  the  obstruction  increases  on  the  other  (the  empty- 
ing of  the  right  ventricle  becoming  less  and  less  complete),  the  blood 
stasis  in  the  veins  of  the  general  system  constantly  increases — hence  the 
danger.  Considering  next  the  influence  of  pneumonia  upon  pregnancy, 
and  of  pregnancy  upon  pneumonia,  he  presents  the  following  conclusions: 
1st.  The  more  advanced  the  pregnancy,  the  more  rapidly  does  pneu- 
monia cause  premature  delivery.  2d.  The  more  advanced  the  pregnancy, 
the  more  unfavorable  is  the  emptying  of  the  uterus.  3d.  The  more  ad- 
vanced the  pregnancy,  the  more  likely  is  the  pneumonia  to  terminate 
fatally.  From  a  comparison  of  the  statistics,  it  would  seem  that  pneu- 
monia affects  pregnancy  less  than  the  exanthemata  and  typhoid  fever,  and 
on  the  contrary  approaches  cholera  in  its  influence: 

Small-pox, 
Typhoid, 
Cholera, 
Measles, 
Pneumonia,     . 

The  Influence  of  Pregnancy  07i  Pneumonia. — Pneumonia  during  preg- 
nancy seems  to  attack  more  often  the  right  than  the  left  side,  which  is 
also  the  rule  in  the  non-parous,  but  pregnancy  causes  an  especial  aggra- 
vation of  the  symptoms;  the  fever  is  marked,  the  temperature  high,  the 
skin  hot  and  dry,  the  pulse  rapid  and  vibrating.  But  the  principal  phe- 
nomenon is  the  disturbance  of  the  respiration,  which,  according  to  Eicau, 
depends  upon  two  sets  of  causes,  one  of  which  (pathological)  is  due  to 
the  pneumonia,  the  other  (physiological)  depends  upon  the  pregnancy. 

A.  Causes  due  to  Pneumonia. — 1st.  The  pulmonary  alveoli  being  the 
seat  of  an  exudation  which  prevents  the  air  from  entering  them,  the  re- 
spiratory surface  is  diminished  and  the  circulation  in  the  inflamed  portion 
is  retarded;  2d.  Hypersemia  and  collateral  oedema  are  produced  in  the 
non-inflamed  portion — two  conditions  which  directly  contract  the  area  of 
hgematosis  (Jaccoud);  3d.  The  pain  in  the  side  compels  the  patient  to 
make  very  shallow  respirations — hence  a  permanent  diminution  of  the 
thoracic  cavity;  4th.  Fever,  in  consequence  of  increased  combustion, 
leads  to  a  greater  consumption  of  oxygen,  and  an  increased  production  of 
carbonic  acid,  at  the  expense  of  the  system;  this  is  one  of  the  most  potent 
causes  of  dyspnoea  (Niemeyer.) 

B.  Causes  due  to  Pregnancy. — Pregnancy,  in  its  turn,  acts  in  two  ways: 
on  the  one  hand  by  increasing  the  size  of  the  uterus,  which,  after  the 
sixth  month,  crowds  up  the  intestines,  the  stomach  and  the  spleen,  and 


31  cases. 

27 

miscarriages. 

38     '' 

22 

li 

53     " 

25 

'• 

15     " 

8 

43     " 

21 

'• 

DISEASES    AFFECTING    PREGNANT    WOMEN.  15 

limits,  in  consequence,  the  contractions  of  the  diaphragm;  on  the  other 
hand,  by  the  changes  which  it  induces  in  the  blood,  tlie  red  discs  being 
diminished  in  size,  and,  since  these  are  the  oxygen-carriers,  the  supply  of 
this  gas  in  the  economy  will  be  lessened,  while,  again,  if  the  pulmonary 
lesion  is  very  extensive,  there  will  be  disturbances  of  the  circulation. 

Statistics  0/43  C'f'ses  of  Pneumonia  in  Fregnancy. 

r  -r,  •      no  \  With  miscarriage,  6  cases. 

I  iiecoveries,  23  ■{  i^r- , ,  .  -,^  °  ' 
T)  t       10AJ-1  A       f  -^  \  Without,  17  cases. 

Before  180th  day  or  preg-  J  ^  ' 

nancy,  28  cases.  1  ,  -.-rr-,, 

-"  -pv     ,,      p.         J  With  miscarriage,  o  cases. 


(  Without,  0. 


r  p  r>^  r   ,•       Q   j  With  premature  labor,  5  cases. 
After  180th  day  of  preg-   i  ^  ^^  ^*^'°^^*'  ^  ^^'^'- 

nancy,  15  cases.  )  c  ■v^T•i.^  i.       n  i.       - 

*^'  Ti    fk     ty         J  Vvith  premature  labor,  o  cases. 

L  JJeatns,  7.-        |  without,  2  cases. 

The  pneumonia,  however,  may  be  slight  or  severe.  In  the  former  in- 
stance, if  uterine  contraction  is  absent  or  can  be  arrested,  resolution  takes 
place  rapidly.  If,  on  the  contrary,  the  pneumonia  is  severe,  it  always 
•causes  abortion.  But,  while  in  the  first  case  abortion  is  usually  followed 
by  relief,  in  the  second  the  pulmonary  lesions  are  aggravated,  extend  over 
I)oth  lungs,  and  death  ensues  in  from  two  to  six  days. 

What  is  the  actual  cause  of  the  expulsion  and  death  of  the  foetus  ? 
Violent  straining,  due  to  coughing,  shock,  the  accumulation  of  carbonic 
acid  in  the  blood  (which,  as  Brown-Sequard  has  shown,  incites  uterine 
contractions),  and  heart-failure  have  been  suggested  by  various  authorities. 
We  believe  in  the  influence  of  all  these  factors,  but  there  is  one  which,  in 
our  opinion,  is  more  powerful  than  all  the  rest;  here,  as  in  variola  and 
typhoid  fever,  it  is  the  elevation  of  the  maternal  temperature,  an  eleva- 
tion which,  by  causing  the  death  of  the  foetus,  transforms  it  into  a  for- 
eign body,  of  which  the  uterus  seeks  to  rid  itself. 

Pi'ognosis. — We  must  consider  this  from  both  the  child's  and  the 
mother's  standpoint. 

1st.  The  Foetiis. — We  have  seen  that  pregnancy  is  often  interrupted, 
and  that,  in  consequence,  the  life  of  the  child  is  often  compromised.  The 
prognosis,  then,  is  exceedingly  grave,  perhaps  a  little  less  so  during  the 
last  three  months,  but  always  very  serious;  and  in  some  cases  we  can 
witness,  as  it  were,  the  death-struggle  of  the  foetus.  The  active  move- 
ments become  disturbed,  irregular  or  spasmodic,  then  they  are  seen  to 
grow  gradually  weaker,  and  finally  to  disappear  entirely.  The  same 
phenomena  appear  in  the  cardiac  beats;  they  are  first  accelerated,  then 
diminish,  become  feeble,  and  finally  cease. 


16  A    TREATISE    OJST    OBSTETRICS. 

2d.  The  Motlier. — Witlioiit  being  nearly  as  grave  for  the  mother  as  it 
is  for  the  foetus^  the  prognosis  in  her  case  is  none  the  less  extremely  seri- 
ous; it  is  sufficient  to  refer  to  the  statistics  presented  by  authorities. 
Grisolle  reports  a  mortality  of  92.8  per  cent.,  Eicau.  35.8.  Bourgeois,  75, 
Wernicii,  21.1,  and  Chatelain,  39.  As  regards  the  effect  of  the  expul- 
sion of  the  foetus,  it  does  not  seem  to  be  favorable  to  the  mother;  thus, 
out  of  82  women  who  miscarried,  58  died,  while  only  16  deaths  occurred 
among  74  women,  who  did  not  abort.  Several  writers,  on  the  contrary, 
affirm  that  abortion  is  folloAved  by  the  resolution  of  the  pneumonia,  and 
hence  the  advice  to  induce  premature  labor.  Wernich,  Hegar,  Martin,  Grus- 
serow,  and  other  German  authorities,  are  positively  opposed  to  this  meas- 
ure, on  the  ground  that  the  sudden  change  of  pressure  within  the  thoracic 
cavity,  resulting  from  the  rapid  emptying  of  the  uterus,  must  inevitably 
produce  fatal  pulmonary  oedema. 

We  believe  that  artificial  abortion  should  not  be  entirely  rejected,  but 
that  it  should  be  reserved  for  special  cases.  In  the  face  of  such  a  grave 
complication  of  pregnancy  as  pneumonia,  we  think  that,  when  all  methods 
of  treatment  have  failed,  and  the  life  of  the  mother  is  seriously  threatened, 
we  have  no  right  to  deny  her  a  possible  chance  of  being  saved,  as  shown 
by  the  cases  cited  b}^  Thirion  and  Aran.  Moreover,  all  writers  agree  in 
affirming  that  the  emptying  of  the  uterus  lessens,  at  least  for  the  time 
being,  the  pulmonary  congestion  and  dyspnoea,  and  consequently  affords 
a  decided  relief  to  the  patient.  Although  this  relief  may  be  only  tempo- 
rary, it  is,  nevertheless,  of  benefit  to  the  woman,  and,  as  the  child  is  almost 
inevitably  doomed  through  the  presence  of  the  disease  alone,  our  course 
should  be  governed  entirely  by  the  mother's  interests.  Unfortunately,  a 
serious  and  weighty  objection  has  been  presented  to  those  who  favor  an 
operation;  it  is,  that  the  induction  of  abortion  and  premature  labor  always 
requires  a  length  of  time,  which  may  vary  from  twelve  to  thirty-six  hours, 
and  even  longer,  during  which  interval  the  disease  may  make  rapid  strides 
and  destroy  the  patients.  This  objection,  we  think,  loses  much  of  its  force 
if  we  adopt  Barnes's  method, — dilate  the  cervix  by  dilators  of  gradually  in- 
creasing size,  and,  when  the  dilatation  is  complete,  terminate  the  labor  as 
rapidly  as  possible,  without  injury  to  the  woman.  As  for  abortion,  we 
believe  that  it  should  be  produced  still  more  rarely,  and  then  by  ruptur- 
ing the  membranes.  The  induction  of  abortion  and  premature  labor  are, 
in  our  opinion,  most  clearly  indicated  in  cases  of  double  pneumonia,  and 
when  pneumonia  occurs  in  a  woman  already  affected  with  cardiac  disease, 
or  in  a  rachitic  subject — in  short,  in  a  woman  whose  respiratory  condition 
was  already  bad  before  the  occurrence  of  the  pneumonia. 

Chatelain,  who  favors  the  induction  of  abortion  in  bad  cases  of  pneu- 
monia, unites  with  GrrisoUe  in  advising  venesection;  this  is  also  the  G-er- 
man  method.  As  for  emetics,  he  reserves  these  until  the  uterus  begins 
to  contract,  when  the  hope  of  saving  both  mother  and  child  is  removed. 


DISEASES    AFFECTING    PREGNANT    WOMEN.  17 

He  believes,  with  Grisolle,  Young,  Parker,  and  Gantillon,  that  tartal 
emetic  provokes  uterine  contractions.  As  long  as  there  is  no  evidence  ol 
delivery,  he  prefers  sulphuret  of  mercury,  either  alone  or  in  combination 
with  digitalis,  which,  in  his  opinion,  is  the  remedy  ;;«r  excellence.  Eicau, 
on  the  contrary,  does  not  employ  venesection,  or  does  not  recommend  it 
unless  pneumonia  is  complicated  by  organic  disease  of  the  heart  in  a  preg- 
nant female.  He  employs  tartar  emetic  and  digitalis,  giving  the  former 
in  emetic  doses,  and  reserves  premature  delivery  as  a  last  resource. 

Pleurisy. 

Pleurisy  seems  to  be  situated  more  frequently  on  the  right  than  on  the 
left  side.  It  is  a  curious  fact  tliat,  while  pneumonia  is  one  of  the  most 
serious  complications  of  pregnancy,  pleurisy  (except  in  exceptionally  severe 
cases)  does  not  appear  to  affect  either  the  course  of  pregnancy  or  the  life 
of  the  mother.  It  was  actually  interrupted  only  twice  in  eighteen  cases  col- 
lected by  us,  the  two  women  who  miscarried  being  in  the  last  month  of 
pregnancy.  (Leopold,  Budin).  Besides,  pleurisy  may  assume  either  of 
the  classical  types,  the  course  of  the  disease  apparently  being  influenced 
principally  by  this  variability  in  its  form.  The  acute,  or  sero-fibrinous 
variety,  is,  according  to  Leopold,  the  most  favorable,  although  the  exuda- 
tive (whether  more  or  less  extensive)  is  the  most  common.  Pneumonia  is 
a  rare  disease  during  pregnancy,  but  pleurisy  is  still  more  infrequent,  since 
we  have  been  able  to  collect  only  eighteen  cases. 

As  in  ordinary  pleurisy,  the  symptoms  are  the  pleuritic  "stitch,"  the 
flatness,  cough,  dyspnoea,  accompanied  with  pain,  fever,  the  compression 
of  the  lung,  which  diminishes  the  area  of  hematosis,  the  compensatory 
congestion  and  oedema  of  the  healthy  lung  (in  the  pregnant  woman,  espe- 
cially during  the  later  months,  the  disturbance  of  respiration  referable 
to  pregnancy  itself  is  added  to  the  pleuritic  dyspnoea),  and  the  displace- 
ment of  the  heart.  As  a  rule,  then,  pleurisy  in  the  gravid  woman  is  be- 
nign, and  it  is  only  in  exceptional  cases  that  it  tends  to  become  purulent 
(contrary  to  its  course  after  delivery),  because  it  usually  runs  its  course 
in  from  thirty-five  to  forty  days.  But  this  is  not  always  the  case,  as 
proved  by  the  facts  recorded  by  Leopold  and  Baratgin,  for  it  may  some- 
times assume  such  a  grave  character  that  thoracentesis  becomes  necessary. 
The  pregnancy  generally  pursues  its  course,  but  when  abortion  and  pre- 
mature delivery  take  place,  these  have  not  seemed  to  exert  any  special 
influence  upon  the  progress  of  the  effusion;  there  was  not  only  no  in- 
creased effusion,  but,  on  the  contrary,  the  dyspnoea  and  accompanying 
malaise  disappeared  rapidly,  almost  immediately,  in  spite  of  the  presence 
of  the  exudation.  Emptying  of  the  uterus,  therefore,  seems  in  itself  to 
relieve  the  oppression  by  freeing  the  thorax;  this  is  especially  true  when 
the  pregnancy  is  quite  advanced.  Pleurisy,  in  fact,  apparently  pursues 
its  usual  course,  and  neither  influences  nor  is  much  affected  by  pregnancy. 
Vol.  n.— 3. 


18  A    TREATISE    OX    OBSTETRICS. 

The  prognosis  is  generally,  but  not  always,  favorable  for  both  mother  and 
child. 

Treatment. — Grisolle  advocates  a  most  thorough  and  vigorous  antiphlo- 
gistic treatment.  Fischl,  Leopold  and  Baratgin  confine  themselves  to  the 
use  of  wet  cups  and  opiates,  combined  with  digitalis,  employing  large  blis- 
ters, diuretics,  mild  purgatives,  milk,  and  a  more  or  less  restricted  diet,  as 
soon  as  the  fever  diminishes.  But,  if  there  is  considerable  effusion,  intense 
dyspnoea,  and  threatened  asphyxia,  with  marked  cardiac  displacement,  are 
we  justified  in  resorting  to  thoracentesis?  It  was  employed  twice  by 
Duguet,  and  once  by  Vendrant  and  Verneuil;  no  accident  resulted  in 
these  three  cases,  and  the  mothers  recovered  more  or  less  speedily.  Others 
have  observed  satisfactory  results  from  thoracentesis;  pregnancy  does  not 
seem  to  contra- indicate  it. 

Pulmonary  Tuberculosis — Phthisis. 

The  most  recent  and  exhaustive  work  on  pulmonary  tuberculosis  is  the 
thesis  of  Gaulard  (1880).  According  to  him,  anaemia  is  the  rule  in  preg- 
nancy. He  accepts  entirely  Peter's  idea  concerning  the  pulihonary  conges- 
tion of  pregnancy,  and  states  that  four  opinions  are  still  held  by  scientists 
regarding  the  relations  between  phthisis  and  pregnancy,  viz. :  1st.  Preg- 
nancy checks  the  development  of  phthisis,  or  arrests  its  course  after  it 
has  already  begun,  Sd.  Pregnancy  accelerates  the  progress  of  tuberculosic; 
3d.  Pregnancy  really  aggravates  tlie  disease,  but  the  latter  undergoes 
marked  amelioration  during  the  early  months;  4th.  Sometimes  pregnancy 
interrupts,  and  seems  to  arrest  the  course  of  the  disease — sometimes,  on 
the  contrary,  it  aggravates  and  hastens  it.  Each  of  these  views  has  its 
eminent  supporters  and  defenders. 

1st.  Pregnancy  checks  the  development  of  phthisis,  or  arrests  its  course 
after  it  has  already  begun.  But  after  delivery  tuberculosis  resumes  its 
course,  and  the  temporary  amelioration  established  during  pregnai:)cy  is 
followed  by  a  relapse  which  often  carries  off  the  patient  in  a  short  time. 
This  opinion,  advanced  by  Cullen,  Borden,  Sims,  and  others,  is  based  on 
the  theory  that  the  growing  uterus  diverts  a  part  of  the  blood  from  the 
lungs  to  nourish  the  foetus,  hence  the  immunity  during  pregnancy.  The 
hemorrhage  accompanying  delivery  insures  amelioration  afterward;  but 
this  is  only  temporary,  because,  as  this  diversion  ceases  after  delivery,  the 
pulmonary  congestion  begins  anew,  and  all  the  phthisical  symptoms  reap- 
pear, and  become  rapidly  aggravated.  Gaulard  calls  attention,  in  connec- 
tion with  this  theory,  to  the  fact  that  pregnant  females  enjoy  no  immu- 
nity from  diseases,  and  that  all  authorities  insist  that  pregnancy  influences, 
more  or  less  injuriously,  every  acute  or  chronic  affection.  There  is,  then, 
no  reason  why  pregnancy,  which  exerts  such  a  particular  disturbing 
effect  upon  a  lung  that  is  the  seat  of  pneumonia,  should,  on  the  other 
hand,  affect  favorably  a  lung  strewn  with  gray  nodules,  or  attacked  with 


DISEASES    AFFECTING    PREGNANT    WOMEN.  19 

tubercular  pneumonia.  If,  as  the  supporters  of  this  idea  believe,  preg- 
nancy produces  a  salutary  derivation  of  blood  from  the  lung  of  a  tubercu- 
lous woman,  why  should  it  produce  such  a  result  only  in  tuberculosis? 
Now,  this  derivation  does  not  exist,  for  the  researches  of  Peter  have  shown 
conclusively  that  pregnancy  unquestionably  causes  pulmonary  congestion, 
and  the  antagonism  between  rickets  and  tuberculosis  (admitted  by  Gubler, 
Beylard  and  Trousseau)  is  not  certain.  As  regards  the  influence  of  deliv- 
ery and  the  puerperium  upon  the  progress  of  phthisis,  Lebert  thinks  that 
it  is  even  more  fatal  than  that  of  pregnancy,  while  Gaulard,  though  ad- 
mitting that  phthisical  females  are  generally  delivered  easily  and  rapidly, 
nevertheless  attributes  to  these  conditions  considerable  influence,  be- 
cause of  the  exertion  demanded  by  the  woman,  exertion  which  increases 
her  weakness  and  induces  attacks  of  pulmonary  congestion.  Now,  it  is 
evident  that  these  violent  and  repeated  congestions  act  unfavorably  upon 
tuberculosis,  at  any  stage  of  its  advance;  they  may  even  lead  to  the  rup- 
ture of  vessels  and  consequent  hemoptysis,  and,  as  Fernet  says,  "  even 
granting  that  haemoptysis  can  not  cause  tubercle,  can  it  not  lead  to  the 
development  of  a  chronic  inflammation  of  the  lung  ?  and,  supposing  this 
inflammatory  process  to  become  caseous,  may  it  not  involve  the  destruc- 
tion of  the  organ  and  all  the  phenomena  of  pulmonary  consumption?" 

The  puerperal  state  also  aggravates  pulmonary  tuberculosis,  and  Lebert 
attributes  this  injurious  influence  to  traumatism,  to  the  feebleness  and 
exhaustion  of  the  woman,  to  loss  of  blood,  and  to  the  lochial  discharge. 
Every  debilitating  agent  favors  the  production  and  development  of  tuber- 
cles; the  puerperium  exerts  such  an  influence,  and  this  applies  more  par- 
ticularly to  lactation.  On  this  point  all  authorities  agree.  But,  in  addi- 
tion to  this  enfeebling  influence  of  the  puerjDeral  condition,  does  it 
not  act  directly  upon  the  respiratory  apparatus  ?  If  during  pregnancy 
the  lungs  are  relieved  of  a  considerable  amount  of  blood,  which  is  diverted 
to  the  uterus,  after  delivery  there  is  a  sudden  change  in  these  relations, 
which  leads  to  congestion,  hemorrhage,  and  acute  exacerbation  of  exist- 
ing inflammations.  According  to  Spiegelberg,  the  sudden  lowering  of 
the  pressure  in  the  aorta  after  delivery  causes  a  corresponding  elevation 
in  the  venous  pressure,  which  is  still  further  increased  by  the  closure  of 
the  uterine  sinuses.  After  labor,  the  diaphragm  can  sink  lower  and  the 
blood  flows  into  the  lungs  more  freely. 

2d.  Pregnancy  not  only  does  offer  no  resistance  to  the  development  of 
phthisis,  but,  on  the  contrary,  it  hastens  and  aggravates  the  course  of 
tuberculosis.  This  opinion  is  based  on  numerous  observations,  in  the 
course  of  which  tuberculosis  existing  before  conception  was  sometimes 
seen  to  advance  more  rapidly  solely  by  reason  of  the  pregnancy,  while, 
again,  a  tuberculosis  previously  latent  may  develop  during  gestation  and 
as  a  result  of  its  influence.  Thus  Gaulard  reported  thirty-two  cases  in 
which  the  disease  existed  before  concejotion,  in  twenty-five  of  which  the 


20  A    TREATISE    ON    OBSTETEICS. 

patient's  condition  was  aggravated,  and  collected  eighty-four  in  which  it 
developed  during  pregnancy  and  was  evidently  aggravated  by  the  srme. 
Caresme  noted  the  appearance  of  tuberculosis  in  twelve  patients  after 
confinement,  two  of  whom  subsequently  gave  birth  to  other  children. 

3d.  Mixed  Opinio7i. — Pregnancy  aggravates  the  course  of  the  disease, 
but  the  latter  undergoes  a  marked  amelioration  during  the  early  months. 
This  view  is  held  by  Gardien,  Capuron,  Pidoux  and  Peter. 

4th.  Finally,  there  exists  a  fourth  view,  still  more  eclectic  in  its  charac- 
ter, according  to  which  pregnancy  sometimes  interrupts  and  seems  to  ar- 
rest the  progress  of  the  disease,  sometimes  hastens  it.  TJiis  is  supported 
by  Portal,  Andral,  and  others. 

The  ages  of  the  patients  have  ranged  from  eighteen  and  a  half  to 
thirty-nine  and  a  half  years,  and  the  interval  elapsing  between  the  initial 
symptoms,  from  the  end  of  gestation,  has  varied  from  a  few  days  to  twenty- 
one  months. 

Pregnancy,  accordingly,  exercises  a  marked  influence  upon  phthisis, 
and  this  influence  will  be  so  much  the  more  injurious  if  this  afferent 
cause  is  combined  with  other  predisposing  ones,  such  as  heredity,  malnu- 
trition, bad  hygiene,  exposure  to  cold,  hard  labor,  scrofula,  pre-existing 
pleurisy,  repeated  pregnancies,  etc.  Lebert  has  presented  the  following 
statistics  showing  the  duration  of  the  disease.  Death  occurred  in  12  per 
cent,  within  three  months,  in  20  per  cent,  within  six  months,  in  44  per 
cent,  between  six  months  and  a  year,  and  in  24  per  cent,  between  one  and 
six  years.  According  to  the  same  writer  the  iiifluence  of  pregnancy  upon 
tuberculosis  is  most  marked  between  the  ages  of  twenty  and  thirty.  He 
draws  the  following  conclusions: 

1st.  Latent  tuberculosis  in  young  girls  most  often  appears  after  mar- 
riage as  a  result  of  pregnancy,  either  the  first  or  a  subsequent  one. 

2d.  In  exceptional  cases,  the  health  in  tuberculous  women  is  not  affected 
even  by  repeated  pregnancies;  in  some  instances  the  children  are  feeble, 
a  certain  proportion  dying  early. 

3d.  Advanced  phthisis  usually  ]3revents  conception;  incipient  phthisis 
does  not  prevent  it,  and  the  pregnancy  goes  on  to  full  term. 

4th.  Abortion,  pregnancy,  and  the  puerjieral  state,  determine  the  de- 
velopment of  phthisis  in  at  least  three-fourths  of  the  cases. 

5th.  Children  born  of  a  phthisical  mother  are  generally  feeble;  they 
often  become  first  scrofulous,  then  tuberculous. 

The  Influence  of  Phthisis  on  the  Product  of  Conception. — This  is  much 
less  pronounced,  though  in  many  instances  it  is  undoubted.  Bourgeois 
noted  96  linng  children  among  124  tuberculous  mothers;  36  infants  con- 
tinued in  good  health,  60  became  scrofulous,  and  22  died  of  tuberculosis 
before  their  seventh  year.  Ortega  observed  95  women,  in  whom  pulmonary 
phthisis  developed  before,  during,  or  after  gestation.  The  disease  ad- 
vanced steadily  in  every  instance.     Although  there  was  sometimes  an 


DISEASES   AFFECTING   PREGNANT    WOMEN.  21 

amelioration  during  gestation,  it  nearly  always  made  rapid  strides  after 
delivery. 

From  these  95  women  there  were  185  pregnancies.  95  went  to  term;  28 
premature  labors;  9  miscarriages;  18  women  did  not  cough  before  preg- 
nancy. In  20,  the  disease  appeared  in  the  first  half  of  pregnancy;  in  11, 
at  term;  in  6,  before  the  9th month;  in  2,  during  lactation;  in  10,  4  weeks 
after  delivery;  in  2,  15  weeks  after  delivery. 

Icterus. 

Icterus  may  present  itself  in  the  pregnant  woman  under  two  forms,  the 
sporadic  and  the  epidemic,  or  the  benign  and  the  innocent,  and  it  is  evi- 
dent that  it  may,  according  to  the  conditions,  exercise  a  more  or  less 
marked  influence  upon  the  product  of  conception.  Icterus  results  from 
an  exaggeration  of  the  physiological  hyperaemia  of  the  liver.  But  in  ad- 
dition to  the  sim]3le  form  there  is  a  malignant  type  peculiar  to  pregnant 
females,  in  which  death  is  caused  by  an  accumulation  in  the  blood  of  the 
components  of  the  bile  which  the  diseased  liver  can  not  eliminate.  Others 
say  that  the  form  of  icterus  observed  in  gravid  women  differs  neither  in 
its  etiology  nor  in  its  development  from  that  which  attends  other  patho- 
logical conditions.  Authorities  differ  widely  in  their  explanations. 
Pouchet  attributes  the  icterus  to  compression  of  the  hepatic  vessels  by 
the  growing  uterus,  Meunier  to  a  similar  pressure  by  the  distended  colon. 
Schroeder  and  others  regard  the  grave  form  as  identical  with  French's 
acute  yellow  atrophy.  It  is  generally  conceded  that  the  toxic  phenomena 
are  due  to  the  presence  of  bile  salts  in  the  blood,  and  especially  to  the 
noxious  influence  of  the  latter  upon  the  nervous  system. 

But  it  is  the  epidemic  form  of  icterus  that  exercises  the  most  marked 
influence  upon  pregnancy.  Among  68  women  thus  affected  42  miscarried, 
30  of  Afhom  died.  Abortion  usually  takes  place  from  three  to  five  days 
after  the  beginning  of  the  disease,  and  not  only  does  this  fail  to  bring 
relief,  but,  on  the  contrary,  the  most  serious  accidents  generally  occur 
subsequently;  and  the  reported  epidemics  of  icterus,  which  have  never 
been  confined  exclusively  to  pregnant  women,  assume  with  them,  as  a 
rule,  an  exceptional  severity. 

The  grave  variety  of  icterus  presents  the  phenomena  so  well  described 
by  Lavoix.  The  coloration  is  more  or  less  intense,  the  urine  contains  bile 
or  the  products  of  albuminoid  decomposition,  such  as  leucin  and  tyrosin, 
3rnd  finally  albumin  and  blood.  There  are  multiple  hemorrhages  (espe- 
cially gastro-intestinal),  petechise  and  nervous  symptoms,  characterized 
particularly  by  coma  or  'stupor.  Its  onset  is  nearly  always  insidious,  being 
often  preceded,  as  in  the  cases  observed  by  David  and  Frerichs,  by  an 
acute  gastric  catarrh;  the  yellow  tinge  developes  slowly  and  constantly, 
accompanied  with  vomiting  of  mucus,  anorexia,  constipation,  cephalalgia, 
a  general  feeling  of  weariness  and  depression,  but  without  fever;  at  other 


22  A    TREATISE    OlST    OBSTETEICS. 

times  the  disease  begins  with  a  rigor,  followed  by  intense  febrile  reaction, 
which  quickly  subsides  when  the  jaundice  appears,  with  or  without  fever, 
but  attended  with  severe  gastric  symptoms,  constipation,  marked  sordes, 
nausea  and  vomiting,  which,  although  occasional  at  first,  may  become 
incessant,  the  vomited  matter  consisting  at  first  of  food,  then  of  glairy 
mucus,  liquid  fseces,  and  bile.  There  is  excessive  thirst,  great  pain  in  the 
epigastrium,  the  liver  and  spleen  become  enlarged  and  very  tender.  This 
condition  continues  for  several  days,  then  follows  the  ataxic  s'tage,  during 
which  abortion  takes  place,  although  this,  according  to  Lavoix,  does  not 
affect  the  progress  of  the  disease.  He  accordingly  disagrees  with  most 
authors,  who  claim  that  abortion  occurs  first,  the  ataxic  symptoms  appear- 
ing subsequently.  However  that  may  be,  this  period  of  ataxia,  convul- 
sions, or  delirium,  is  characterized  by  extreme  agitation,  associated  with 
disorderly,  involuntary,  and  spasmodic  movements.  There  is  intense 
cephalalgia,  delirium  with  subsultus  tendinum,  disturbances  of  vision, 
dilated  pupils,  while  at  the  same  time  there  may  be  high  fever  or  almost 
none.  The  urine  is  scanty,  reddish  or  bloody,  often  containing  albumin, 
and  depositing  from  four  to  nine  per  cent,  of  solid  residue,  consisting 
principally  of  leucin,  tyrosin  and  gelatinous  extractions,  with  traces  of 
uric  acid  (not  urea),  and  slight  traces  only  of  ammonium.  Then  comes 
the  stage  of  coma,  sometime?  interrupted  by  convulsive  phenomena,  but 
generally  very  brief,  and  soon  ending  in  death.  Hemorrhages,  although 
they  occur,  are  comparatively  rare,  being  generally  confined  to  those  which 
accompany  abortion  and  delivery.  The  pulse  in  simple  or  benign  icterus 
remains  below  the  normal,  while  in  the  grave  form  it  ranges  from  80  to 
120  several  times  during  the  same  day.  Grave  icterus  in  the  pregnant 
female  generally  terminates  fatally  within  five  or  six  days,  sometimes 
sooner.  In  some  cases  the  disease  progresses  so  rapidly  that  there  is  no 
time  for  abortion  to  take  place  (Woillez);  but  death  is  not  the  inevitable 
consequence  of  grave  icterus,  and  there  are  a  certain  number  of  cases  in 
which  a  cure  took  place  in  spite  of  the  extreme  severity  of  the  disease. 
"When  the  patient  die,  we  find,  on  autopsy,  fatty  degeneration  of  the  hepa- 
tic cells,  the  kidneys,  heart,  muscular  system,  but  the  liver  is  rather  in- 
creased in  size  than  diminished  (Lavoix),  and  it  is  generally  softened. 
The  mucous  membrane  of  the  bile  ducts  is  necrosed.  The  abdominal 
cavity  contains  a  yellowish  or  reddish,  semi-purulent  exudation,  some- 
times in  large  amount;  the  spleen  is  normal  or  softened,  the  peritoneum 
is  covered  with  ecchymotic  spots,  the  lungs  are  congested,  oedematous, 
and  filled  with  yellowish  fluid.  The  pericardium  contains  a  certain 
amount  of  yellowish  serum,  and  there  are  numerous  sub-pericardial  ecchy- 
moses.  The  heart  is  small,  flabby,  soft,  fatty,  and  pale,  containing  with- 
in the  right  ventricle  adhesive  blood,  or  a  few  soft,  spongy,  blackish 
clots.  The  meninges  present  a  slight,  often  insignificant  congestion. 
The  autopsy  in  the  case  of  the  foetus  shows  nothing  striking. 


DISEASES    AEFECTING    PREGNANT    WO.MEN".  23 

We  should  then,  it  is  evident,  always  be  very  reserved  in  our  prog- 
nosis, even  when  the  icterus  appears  in  a  mild  form,  and  we  consider 
Behier  altogether  too  positive  in  his  opinion  that  icterus,  occurring  dur- 
ing the  last  days  of  pregnancy,  is  of  a  benign  character,  and  that,  with- 
out being  quite  neglected,  it  is  to  be  considered  as  of  merely  secondary 
importance. 

We  are  not  concerned  here  with  icterus  which  occurs  after  labor;  it 
may  be  said,  however,  that  it  is  very  grave,  because  we  may,  with  Her- 
vieux,  regard  it  in  a  great  majority  of  cases  as  symptomatic  of  puerperal 
poisoning,  and  as  one  of  the  consequences  of  puerperal  peritonitis. 

Treatment. — There  can  be  no  question,  it  is  evident,  as  to  the  induc- 
tion of  abortion  or  even  of  premature  labor,  in  the  presence  of  the  disas- 
trous results  that  follow  abortion  in  cases  of  icterus.  We  should  limit  our- 
selves, then,  to  exclusively  medical  treatment.  To  relieve  the  hepatic 
pains  by  leeches  and  cupping,  to  oppose  the  condition  of  sordes  by  ipecac, 
the  constipation  by  purgatives,  the  vomiting  by  ice  and  acid  drinks,  Vichy 
and  Seltzer  water  and  alkaline  baths — in  a  word,  we  adapt  our  medicine 
to  the  symptoms,  treating  them  as  they  appear,  by  appropriate  remedies. 
Lavoix  advises,  as  a  prophylactic,  tincture  of  aconite  and  quinine;  Cazeaux 
change  of  residence. 

Syphilis, 

All  authors  agree  in  admitting  the  influence  of  syphilis  on  pregnancy, 
and  of  pregnancy  on  syphilis;  but  there  is  a  particular  factor  which  im- 
parts to  this  mutual  influence  special  forms — the  age  of  the  syphilis. 

1st.  Sometimes  a  woman  is  pregnant  when  she  contracts  syphilis,  and 
the  infection  can  then  occur  either  at  the  beginning,  during  the  first 
months  after  conception,  or  during  the  latter  months. 

2d.  Sometimes  a  woman  becomes  pregnant  at  the  same  time  that  she 
contract  syphilis.     The  infecting  coitus  has  also  been  fruitful. 

3d.  Pregnancy  occurs  in  a  woman  who  is  healthy  and  in  good  condition,, 
and  who  has  never  presented,  nor  does  she  then  present,  any  evidence, 
old  or  recent,  of  syphilis,  but  whose  husband  has  possessed,  or  still  pos- 
sesses, a  syphilitic  diathesis. 

4th,  Pregnancy  occurs  in  a  woman  affected  by  syphilis  at  a  time  more 
or  less  remote;  it  was  not  treated,  and  the  woman  presents  or  does  not 
present  traces  of  ifc. 

In  the  first  place.  What  are  the  evidences  of  syphilis  most  often  met 
with  in  the  pregnant  female?  According  to  all  the  authors  who  have 
studied  the  disease,  these  are  especially  the  primary  and  secondary  mani- 
festations. Tlie  tertiary,  on  the  contrary,  are  rare.  These  manifestations 
are  greatly  influenced  in  tlieir  course  and  in  their  character  by  gestation. 
This  influence  of  pregnancy  is  manifested  in  two  ways,  either  locally  or 
generally,  and  both  chancres  and  syphilides  are  subject  to  the  disturbing 


24  A    TEEATISE    ON"    OBSTETRICS. 

circulatory  effects  Avliicli  exist  in  the  pre_^nant  woman,  and  which  result 
either  in  passive  or  active  congestion,  x'^ccording  to  Fournier,  pregnancy 
complicates  the  pox  by  adding  to  it  its  own  ansemia,  its  depressing  influ- 
ence, its  neuralgic  tendency,  disorders  of  nutrition,  etc.  As  regards  the 
local  manifestations,  syphilis  predisposes  to  the  development  of  mucous 
syphilides,  which  assume  great  importance.  The  induration  is  slightly 
marked,  being  a  simple  hardened  scale— parchment  chancre;  but,  while 
in  the  non-pregnant  woman  the  duration  of  the  chancre  does  not  gener- 
ally exceed  from  four  to  five  weeks  (rarely  more,  often  less),  in  the  preg- 
nant female  the  mean  duration  of  the  chancre  is  about  two  months  and 
twenty  days. 

According  to  Fournier,  mucous  papules  are  not  only  very  common,  but 
they  develop  in  pregnant  women  a  remarkable  exuberance,  assume  rap- 
idly the  budding,  vegetating,  or  hypertrophic  variety,  and  often  form 
actual  tumors,  which  invade  and  distort  the  entire  vulva.  Moreover,  they 
are  always  more  rebellious  than  usual,  and  disappear  more  slowly. 
Syphilitic  ulcers  are  quite  frequent  in  pregnant  women;  they  are  livid,  of 
a  violet  color,  excavated,  and  are  rendered  still  deeper  by  the  vascular 
turgescence  of  the  parts.  They  usually  persist  for  a  longer  or  a  shorter 
period  and  often  tend  to  progress.  It  is  sometimes  extremely  difficult  to 
cause  them  to  cicatrize  before  delivery.  While  the  duration  of  syphilides, 
in  the  non-pregnant  state,  varies  from  two  to  two  and  one-half  months, 
it  varies  from  three  to  three  and  one-half  during  pregnancy.  Guerin, 
who  agrees  with  Fournier  on  this  point,  afiirms  that  during  pregnancy 
the  mucous  patches  increase  in  number,  and  grow  in  spite  of  general  and 
local  treatment  as  long  as  the  pregnancy  continues;  or,  that  if  they  dis- 
appear for  a  short  time,  they  have  a  great  tendency  to  return,  not  only 
on  the  genitals  but  also  on  the  fauces,  tongue,  and  lips.  Their  persist- 
ence, according  to  him,  proves  that  treatment  is  not  as  effective  as  it  is 
in  the  non-pregnant  condition. 

The  Influence  of  Si/pJiilis  on  Pregnancy. — Although  the  influence  of 
syphilis  on  pregnancy  is  unquestioned,  it  is,  however,  not  absolute,  and 
varies  with  the  conditions  according  to  which  syphilis  appears  in  women. 
The  important  feature  is  the  frequency  of  abortion  and  premature  deliv- 
ery. Among  657  syphilitic  females,  231  miscarried,  while  426  were  de- 
livered at  term  of  living  and  dead  children.  But,  as  we  have  seen,  four 
cases  may  be  presented,  and  we  must  consider  here: 

The  father  alone  is  syphilitic.  The  mother  has  never  presented,  nor 
does  she  now  present,  any  manifestations  of  syphilis.  The  idea  of  direct 
transmission  from  the  father  to  the  foetus,  without  participation  on  the 
part  of  the  mother,  which  was  opposed  for  some  time,  has  been  defended 
by  Trousseau,  Diday,  Bourgeois  and  many  others.  It  remains  to-day 
incontestible,  and  we  have  observed  numerous  cases. 

As  regards  maternal  syphilis  we  have  seen  that:  1st.   The  woman  may 


DISEASES   AFFECTING   PEEGISTANT    W03IEN.  25 

be  affected  before  conception;  2d.  Sypliilis  and  pregnancy  may  begin 
simultaneously;  3d.  Syphilis  may  have  been  contracted  after  conception, 
at  a  period  of  pregnancy  more  or  less  advanced. 

1st.  Si/pJiilis  existing  before  Concept io7i. — A  syphilitic  woman  who  be- 
comes pregnant  is  far  more  predisposed  to  abortion  than  a  pregnant  woman 
who  subsequently  becomes  syphilitic.  This  is  especially  observed  in  cases 
of  repeated  abortion,  and  it  is  now  a  classical  fact  that  all  accoucheurs, 
both  in  France  and  abroad,  with  a  few  exceptions  (happily  rare),  advise 
that,  Avhen  successive  abortions  are  observed  in  the  same  woman  without 
apparent  cause,  she  should  be  put  on  antisyphilitic  treatment,  and  that, 
too,  not  only  when  no  specific  manifestation  is  present,  but  even  when 
she  has  never  shown  any. 

When  the  pregnancy  advances  to  term,  the  child  may;  1st.  Be  born 
healthy  and  in  good  condition,  and  may  remain  so  (this  is  exceptional); 
2d.  It  may  be  healthy  when  born,  but  may,  during  the  first  three  months 
after  birth,  rarely  later,  show  symptoms  of  syphilis  (quite  frequent) ;  3d. 
It  may  show  symptoms  of  syphilis  from  its  birth,  and  may  then  either  suc- 
cumb quickly  (the  rule),  or  may  be  cured  by  appropriate  treatment  (the 
exception);  4th.  Although  apparently  healthy  when  born,  it  may  die 
within  a  few  days,  either  by  reason  of  its  feeble  condition  in  consequence  of 
premature  delivery  (often),  or  from  convulsions  (when  delivered  at  term.) 

2d.  SypJiilis  and  Conce]}tio7i  are  concomitant. — Here,  too,  abortion  is 
the  rule,  or  at  least  delivery  is  often  premature,  and  in  consequence  of 
the  rigid  treatment  to  which  the  mother  is  subjected  the  child  may,  in 
exceptional  cases,  be  born  healthy  (or  without  evident  traces  of  syphilis), 
and  then,  as  in  the  former  instance,  may  either  be  cured  or  may  succumb. 

3d.  Syphilis  is  contracted  after  the  fourth  or  fifth  Month  of  Pregnancy, 
— In  this  case  the  danger  is  less.  Abortion  does  not  take  place,  but  de- 
livery is  often  premature,  and  when  the  foetus  reaches  full  term  it  may 
frequently  be  born  healthy;  or  it  may  be  apparently  healthy  when  born, 
but  may  present  syphilitic  manifestations  within  two  or  three  months 
after  birth. 

4th.  Finally,  the  Woman  contracts  Syphilis  only  at  the  Termination  of 
Pregnancy. — Then  the  danger  is  almost  7iil;  pregnancy  is  concluded  in 
the  ordinary  manner  at  term  by  the  birth  of  a  living,  healthy  child.  It 
is  during  the  secondary  stage,  that  is,  from  the  fourth  month  to  the 
second  year  of  this  period,  that  maternal  syphilis  seems  to  predispose 
most  to  abortion.  But,  as  we  know,  syphilis  may  be  active  at  the  end  of 
three,  four,  five,  six  years,  or  even  longer.  Those  women  are  most  prone 
to  abort  who  are  affected  with  severe  forms  of  the  disease — those  who, 
to  use  Fournier's  expression,  are  affected  "  riiclement  et  visceralement;"  but, 
abortion  may  occur  in  all  forms  of  the  disease,  even  the  lightest,  and  is 
often  the  sole  expression  of  the  diathesis.  "  There  are  a  certain  number 
of  women,"  says  Fournier,  "who  abort  exclusively  because  of  syphilis. 


26  A    TREATISE    OlST    OBSTETRICS. 

'without,  at  the  same  time,  presenting  or  having  presented,  for  a  period 
more  or  less  remote,  any  appreciable  specific  symptoms."  In  his  opinion, 
then,  even  latent  syphilis  is  still  capable  of  causing  abortion.  We  share 
this  conviction  fully. 

We  see,  therefore,  that  syphilis  is  one  of  the  diseases  that  deserves  the 
greatest  attention  on  the  part  of  the  accoucheur,  and  we  realize  the  full 
importance  of  treatment  in  the  interest  of  the  mother  as  well  as  the  child. 
Some  writers  (happily  few)  have  nevertheless  insisted  that  these  ravages 
should  be  attributed,  not  to  the  pox,  but  to  its  antidote,  mercury.  Such 
a  view  could  not  be  too  strongly  opposed,  and  all  obstetricians  agree  with  all 
the  syphilographers  in  advising  mercurial  treatment  during  pregnancy, 
not  only  in  the  case  of  women  who  are  actually  affected  by  syphilis,  or 
who  show-  evidences  of  it,  but  in  every  instance  in  which  the  father  has 
had  syphilis,  and  where  there  have  been  repeated  abortions  without  any 
known  cause. 

Lead-Poisoning. 

Constantin  Paul  was  the  first  to  point  out  the  influence  of  lead-poison-' 
ing  on  gestation.  He  has  shown,  in  short,  that  plumbisni  manifests  it- 
self not  only  by  its  classical  effects,  but  also  by  the  death  of  the  foetus, 
or  the  premature  death  of  the  child,  no  matter  whether  the  father  or 
mother  was  exposed  to  the  poison.  Three  accidents  may  occur  in  women 
thus  affected :  1st.  Metrorrhagia,  more  or  less  profuse,  is  observed  in 
women  who  have  had  amenorrhcea  for  several  months,  with  every  evi- 
dence of  possible  pregnancy;  2d.  Abortion  from  the  third  to  the  sixth 
month;  3d.  Premature  delivery,  in  which  the  child  is  born  dead  or 
moribund. 

Moreover,  during  the  first  three  years  of  infant  life  the  mortality  is 
above  the  average.  Constantin  Paul  describes  four  classes,  viz.:  1st. 
Women  who  have  had  more  or  less  severe  manifestations  of  plumbism, 
and  whose  pregnancies  have  varied  greatly  from  normal.  Out  of  fifteen 
pregnancies  occurring  in  four  women,  there  were  ten  abortions,  onl}-  one 
child  being  born  alive;  2d.  Women  who  have  had  normal  deliveries  be- 
fore being  exposed  to  the  influence  of  lead,  and  who  afterwards  observed 
its  effects  upon  the  product  of  conception.  Thirty-six  cases  of  pregnancy 
were  noted  under  this  head;  twenty-nine  children  were  dead  born,  and 
only  two  were  living  at  the  end  of  a  year;  3d.  Women  who  cease  to  work 
in  lead.  One  case  was  observed.  A  lead-worker  who  had  aborted 
five  times,  gave  up  her  occupation,  and  at  her  next  confinement  was  de- 
livered of  a  healthy  child.  4th.  Women  who  work  in  lead,  and  who  give  up 
their  occupation,  but  resume  it  later.  Two  women,  after  working  in  lead, 
stopped  for  three  or  four  years,  during  which  time  they  had  three  living 
children;  on  returning  to  their  old  work-shop  they  had  repeated  miscar- 
riages. 


DISEASES    AFFECTING    PREGNANT    WOMEN.  27 

III /l nonce  of  the  Fatlier. — The  fatal  influence  of  lead  is  felt  equally  as 
•much  Avhen  the  father  has  handled  lead.  Of  seven  women  who  married 
men  working  in  lead:  1.  7  labors  at  term,  1  miscarriage;  2.  2  pregnancies, 

1  miscarriage,  1  premature  labor;  3.   2  miscarriages,  3  labors  at  term;  4. 
■J  pregnancies — 3  miscarriages,  1  at  term;  5.  3  pregnancies — 1  miscarriage, 

2  at  term;  6.   12  pregnancies — 1  miscarriage,  10  children  died  in  3  years; 
7.   5  pregnancies — 2  miscarriages,  all  the  children  died  shortly. 

If,  then,  lead-poisoning  does  not  prevent  fecundation  and  influence 
menstruation,  its  action  upon  the  foetus  is  incontestable,  as  the  following 
observations  prove: 

Seventy-three  children  were  born  dead  in  one  hundred  and  twenty-three 
pregnancies.  Miscarriages,  4;  premature  labors — 1  at  7,  3  at  8  months — 
4;  dead  children,  5;  children  dying  in  first  year,  20;  second  year,  8;  third 
year,  7;  later,  1;  living  children,  14;  living  children  beyond  3  years, 
10;  metrorrhagia  dependent  on  miscarriages,  15. 

The  Influence  of  Tobacco  on  Peegnancy. 

In  connection  with  the  fatal  influence  which  lead  exerts  upon  concep- 
tion, that  of  nicotine  must  be  mentioned.  The  researches  of  Decaisne,  Sarre, 
and  others,  show  that  miscarriages  are  very  frequent  among  women  em- 
ployed in  tobacco  manufactories,  and  that  such  children  as  are  born  alive, 
are  poor,  wasted,  and  short-lived.  Kostial  observed  among  506  new-born 
infants,  181  deaths  during  the  first  year;  104  died  from  cerebral  affections 
attended  with  convulsions.  The  majority  of  the  deaths  occur  during  the 
ages  of  two  to  four  months — that  is  to  say,  during  the  period  when  the 
mothers  resume  their  labor,  and  nurse  their  infants  with  milk  saturated 
with  nicotine.  Jacquemart  noted  forty-five  cases  of  abortion  and  pre- 
mature delivery  among  100  cases  of  pregnancy  in  tobacco-workers,  fifteen 
children  died  shortly  after  birth,  and  the  mortality  of  such  of  the  survivors 
as  were  nursed  by  their  mother  was  ten  per  cent,  higher  than  among  those 
who  were  brought  up  on  the  bottle. 

Hysteria — Epilepsy. 

We  consider  these  two  affections  together,  although  they  are  quite  dif- 
ferent, because  there  is  a  form  that  serves,  as  it  were,  as  a  bond  of  union 
between  them — hystero-epilepsy. 

The  Influence  of  Pregnancy  on  Hysteria  and  E2nlepsy. — Authors  differ 
widely  regarding  the  influence  of  pregnancy  on  hysteria.  While  many 
advise  marriage  and  pregnancy,  and  think  that  the  hysterical  attacks  are 
relieved  by  gestation;  others,  on  the  contrary,  believe  that  not  only  does 
pregnancy  fail  to  relieve  hysteria,  but  that  the  attacks  at  the  beginning- 
become  more  severe  and  frequent.  They  nearly  always  disappear,  it  is 
true,  during  the  latter  months.  Briquet  again  affirms,  that  pregnancy 
has  sometimes  a  favorable,  sometimes  an  unfavorable  action.     "  Hysteri- 


28  A    TREATISE    ON    OBSTETRICS. 

cal  manifestations/'  according  to  liim,  "  depend  far  more  upon  moral 
causes  and  upon  the  condition  of  tlie  women  at  the  time,  tlian  upon  any- 
thing else." 

As  regards  epilepsy,  there  is  pretty  much  the  same  divergence  of  opin- 
ion. Fernel  has  seen  epilepsy  develop  during  pregnancy  and  disappear 
after  delivery;  Tissot  regards  epilepsy  as  frequent  during  pregnancy,  and 
sometimes  the  latter  condition  seems  to  diminish  the  frequency  of  the  at- 
tacks, sometimes  to  increase  them.  We  believe  that,  on  the  whole,  the 
latter  opinion  should  be  accepted.  Sometimes  pregnancy  modifies  epi- 
lepsy by  postponing  the  attacks  and  rendering  them  much  less  severe; 
sometimes,  on  the  other  hand,  pregnancy  exerts  a  disastrous  influence. 

The  Influence  of  Hysteria  and  Epilepsy  on  Pregnancy. — This  seems  to 
be  almost  nil,  and  we  have,  ourselves,  seen  in  two  cases  out  of  three,  preg- 
nancy go  on  to  term,  while  in  the  third,  abortion  did  not  occur,  notwith- 
standing the  fact  that  the  attacks  were  so  severe  as  to  cause  the  death  of 
the  patient. 

TkAUMATISM   DURIIfG   PrEGN'ANCY. 

1.  Tlie  Influence  of  Traumatism  on  Pregnancy. — Gueniot  shows  that  in 
]ST6  the  total  number  of  observations  amounted  to  245,  since  which  time 
many  others  have  been  added.  The  following  points  are  to  be  noted: 
1st.  There  is  no  fixed  law  regarding  the  innocuous  influence  of  trauma- 
tism on  pregnancy.  These  consequences  are  entirely  different,  according 
to  the  feeble  or  increased  irritability  of  the  uterus,  the  healthy  or  diseased 
state  of  the  foetus,  or  the  freedom  of  the  mother  from  certain  morbid  con- 
ditions; 2d.  These  results  vary,  but  to  a  less  extent  according  as  the 
injury  does,  or  does  not,  affect  directly  the  genital  tract,  as  the  hemor- 
rhage at  the  time  is  slight  or  profuse,  and  as  it  is,  or  is  not,  complicated 
by  an  inflammatory  process  of  some  intensity.  Thus,  when  a  perfectly 
healthy  pregnant  female  is  injured  (wha.tever  may  be  the  character  or 
severity  of  the  lesion),  the  pregnancy  is  not  usually  affected.  There 
are  three  exceptions  to  this  rule,  viz.:  A.  If  the  lesion  is  situated  in  the 
genital  tract,  or  ano-perineal  region,  the  course  of  pregnancy  is  often  in- 
terrupted, and  the  injurious  effect  seems  to  depend  rather  on  the  duration 
or  repetition  of  the  traumatic  action  than  on  its  degree  of  intensity;  B. 
Again,  whatever  may  be  the  seat  of  the  lesion,  if  it  causes  in  a  very  short 
time  a  considerable  loss  of  blood,  the  pregnancy  is  seriously  threatened, 
and  the  woman's  life  is  more  or  less  compromised;  0.  Finally,  if  the 
wound  is  subsequently  complicated  by  inflammation  (erysipelas,  phlegmon, 
lymphangitis,  etc.),  it  can,  through  this  cause,  interrupt  the  pregnancy; 
3d.  When  pregnancy  is  complicated  by  a  pathological  condition  (abnor- 
mal irritability  of  the  uterus,  disease  or  hypertrophy  of  the  ovum,  albu- 
minuria, etc.),  the  wound,  however  slight  it  may  be,  and  wherever  it  may 
be  situated,  generally  leads  to  the  premature  expulsion  of  the  product  of 


DISEASES    AFFECTING    PREGNANT    WO.^IEN.  29 

conception.  In  this  instance  the  true  cause  of  the  trouble,  which  is,  attri- 
buted to  pregnancy,  really  lies  in  the  organic  or  functional  affection  that 
complicates  the  latter  condition,  and  not  in  the  injury,  which  simply  acts 
as  an  adjuvant  or  secondary  cause;  4th.  Nevertheless,  in  view  of  the 
extreme  difficulty,  and  often  impossibility,  which  the  surgeon  encounters 
in  diagnosticating  some  of  these  morbid  conditions  (uterine  irritability, 
disease  of  the  ovum,  etc.),  it  is  well  to  be  very  circumspect  in  performing 
operations  during  pregnancy.  If  the  surgical  lesion  will  involve  the 
genital  tract,  the  pregnant  condition  offers,  save  in  cases  of  necessity,  a 
formal  contra-indication  to  the  operation. 

2.  Tlie  Injluence  of  Pregnancy  on  Traumatism.  — If  we  consider  the  facts 
thus  far  published,  pregnancy,  in  the  great  majority  of  cases,  does  not 
exert  any  injurious  influence  upon  traumatism.  Thus,  contusions  and 
wounds,  even  dislocations  and  fractures,  are  not  followed  by  any  higher 
mortality  in  pregnant  women  than  in  other  individuals;  moreover,  the 
cure  of  such  injuries  takes  place  in  the  usual  manner  and  within  the 
period  that  is  common  to  each  variety  of  lesion.  The  following  excep- 
tions, however,  are  included  under  this  rule:  A.  When  the  injury 
affects  the  genital  tract,  it  may  be  rendered  milder  or  complicated  in  its 
course,  or  its  termination  may  be  delayed,  by  the  existence  of  pregnancy; 
B.  This  holds  true  even  after  the  third  month  of  gestation,  provided  that 
the  injury  affects  the  loAver  limbs  or  a  region  in  which  vascular  changes 
have  taken  place.  The  ordinary  complications  in  A  and  B  are  hemor- 
rhage, lymphangitis,  erysipelas,  gangrene  and  atonic  ulceration;  C.  As 
regards  fractures  in  particular,  although  cases  of  non-union  during  preg- 
nancy are  very  exceptional,  this  condition  can  not  always  be  exonerated 
from  exercising  a  certain  influence  in  retarding  the  formation  or  the  so- 
lidity of  the  callus;  D.  In  complicated  pregnancy  (above  all,  where  the 
complication  tend  s  to  produce  premature  expulsion  of  the  ovum),  wounds, 
by  leading  to  abortion,  sometimes  acquire  indirectly  a  gravity  quite  un- 
usual, because  the  woman  is  then  exposed  to  the  different  accidents  that 
regularly  accompany  delivery — metrorrhagia,  metro-peritonitis,  etc. 

3.  Contrary  to  the  received  opinion,  the  puerperal  state  opposes,  as  a 
rule,  neither  the  regular  healing  of  wounds  nor  the  union  of  fractures, 
provided  that  these  injuries  occur  simultaneously  with  pregnancy  or 
delivery.  The  exceptions  to  this  rule  must  be  ascribed  either  to  the 
particular  region  affected  (the  genital  tract),  to  the  fever  that  sometimes 
ushers  in  the  flow  of  milk,  or,  above  all,  to  a  general  or  local  morbid  ten- 
dency in  the  woman.  Wounds  occurring  after  parturition  seem  to  present 
a  special  gravity,  which  would  seem  to  be  related  to  the  disturbance  re- 
ferable to  the  physiological  involution  of  the  organs.  Hence  the  indica- 
tion to  defer  until  three  or  four  months  after  delivery  all  operations  not 
urgent,  which  may  involve  the  genital  tract  or  the  lower  limbs.  It 
follows  that  surgical  lesions  during  pregnancy  are  far  from  being  so  serious 


30 


A   TEEATISE    ON   OBSTETRICS. 


as  we  suppose,  and  that  in  the  case  of  a  tumor,  which  is  developing  rapidly 
and  is  threatening  life,  we  sliould  resort  to  extirpation  rather  than  to 
the  induction  of  premature  labor. 

[In  connection  with  this  subject,  we  append  the  statistics  collected  by 
Mann,  of  Buffalo,  and  which  appear  in  a  paper  published  in  Vol.  7,  of 
Am.  Gyn.  Trans. 


Nature  of  Operation.                 '                         Number. 

Abortions.  Deaths. 

Venereal  warts  of  vulva, 

.     19 

3 

"     "  vagina,    . 

.       3 

Elephantiasis  vulvae, 

.       2 

Sarcoma             " 

.       1 

Lipoma               '"' 

1 

Cyst                     "         .         .         .         . 

.       1 

Abscess  vulvo-vag.  glands,  . 

5 

1            1 

Unruptured  hymen,    .         .         ,        \ 

.       1 

Polypus  vagina,          .         .         ,         . 

4 

1            1 

Cyst           ''..... 

1 

Abscess      "                  .... 

.       1 

Stenosis     ''         .         ,         . 

1 

Ant.  Elytrorrhaphy,  .... 

.       1 

Vesico-vag.  fist.,          .... 

.       5 

2 

Ureth.  caruncle,          .         „         ,         . 

1 

Dilat.  of  ureth.  for  stone,   . 

5 

Cystotomy,                    .          -         .          . 

2 

Recto-vag.  fistula,       .         „         .         . 

2 

Stricture  of  rectum,    .... 

1 

1 

Fissure  in  Ano,  .         .         ,         .         , 

3 

2 

Fistula  in  Ano,  .         .         .         .         ^ 

1 

1            1 

Euptured  perineum,   ,         .         .         : 

7 

1 

Polyp  of  cervix  (small), 

3 

1 

"      "       "      (large),       .... 

7 

3            1 

Lacerated  cervix,         ..... 

6 

2 

Cancer         "               .... 

6 

2 

00 


20 


The  whole  paper  is  of  interest,  and  our  readers  are  referred  to  it  for 
Jnore  detailed  information  in  regard  to  these  operations. — Ed.] 

Goitre. 

TJie  Influerice  of  Goitre  on  Pregnancy. — Of  all  the  writers  who  have 
called  attention  to  the  greater  frequency  of  goitre  in  woman  than  in 
man,  Jeans-Louis  Petit  was  the  first  to  note  its  influence  on  the  puerperal 
state.  Tarnier  says,  that  hypertrophy  of  the  thyroid  gland  is  generally 
inconsiderable,  causes  no  trouble  during  pregnancy,  and  after  delivery 
resumes  nearly  its  original  size.  Goitre  does  not  seem  to  us  to  be  quite 
as  rare  as  is  generally  supposed,  and  although  the  number  of  observa- 
tions is  limited,  it  does  not  usually  lead  to  any  serious  accidents.  How- 
ever, this  is  not  always  true,  and  it  may  in  some  instances  assume  an 


DISEASES    AFFECTING-    PREGNANT    W03IEN.  31 

exceptional  gravity.  Ollivier,  who  affirms  tliat  goitre  usually  appears 
from  the  third  to  the  fourth  month  of  pregnancy,  recognizes  several  dis- 
tinct forms,  viz.: 

1st.  Subacute  and  Transient  Goitre. — It  dev elopes  slowly,  and  only  in 
exceptional  cases  assumes  a  considerable  size,  being  often  iinrecognized 
during  the  first  pregnancy.  No  pulsation  is  present,  the  health  is  not 
affected,  and  the  enlargement  often  disappears  almost  entirely  after  de- 
livery. 

2d.  Acute  and  Grave  Goitre. — This  form  developes  rapidly,  and  gives  rise 
to  attacks  of  suffocation.  Tarnier  reports  a  case  in  which  death  occurred 
from  asphyxia;  Bailly  one  that  terminated  fatally  in  spite  of  tracheotomy. 
Suppuration  sometimes  occurs,  the  condition  being  a  true  thyroiditis. 

3d,  Chronic  Goitre. — Sometimes  the  enlargement  appears  during 
pregnancy,  and  remains  stationary  after  delivery,  or  even  undergoes  a 
slight  increase  in  size  at  each  successive  pregnancy;  sometimes,  the  acute 
form  becomes  chronic,  or  the  goitre  is  only  recognized  after  delivery. 
Finally,  chronic  goitre  in  the  gravid  woman  may  pursue  its  course  until 
a  more  or  less  advanced  stage  of  pregnancy,  when  it  rapidly  enlarges, 
so  as  to  compress  the  trachea,  and  cause  suffocation. 

Pastriot  divides  goitres  from  an  anatomical  standpoint  into  three  vari- 
eties, the  vascular,  parenchymatous,  and  cystic.  In  the  vascular  there  is 
congestion  and  apoplexy  of  the  thyroid  gland.  During  the  straining 
that  attends  delivery,  the  dilated  vessels  rupture,  leading  to  hemorrhage 
at  some  point  in  the  goitre,  and  effusion  of  blood  between  the  lobules. 
In  the  second  form,  there  is  a  true  hypertrophy  of  the  fibrous  tissue,  the 
enlargement  being  due,  not  to  the  thyroid  gland  itself,  but  to  a  gelatinous 
fluid  which  fills  the  surrounding  cellular  tissue  (cellular  goitre.)  Lar- 
rey,  again,  has  described  an  emphysematous  goitre,  which  he  thinks  is 
independent  of  the  thyroid  gland,  being  due  solely  to  emphysema.  In 
the  cystic  variety,  as  described  by  Pastriot,  there  is  a  cavity  containing  a 
material  (generally  fluid,  sometimes  solid),  which  has  formed  in  the  midst 
of  the  normal  gland  elements,  Porcher  admits  the  existence  of  two 
forms,  simple  hypertrophy  of  the  thyroid,  and  glandular  or  vesicular 
goitre,  also  the  fibro -cellular,  colloid,  and  vascular  varieties.  He  believes 
that  menstruation,  as  well  as  pregnane}^,  affects  the  development  of  the 
swelling. 

Diagnosis  and  Prognosis. — The  enlargement  usually  begins  gradually, 
or  else  it  appears  suddenly  during  the  efforts  of  parturition.  Although 
at  first  of  small  size,  it  increases  in  size  with  each  pregnancy,  and  then 
either  disappears  after  delivery,  remains  stationary,  or  continues  to  de- 
velop, and  is  attended  with  evidences  of  compression,  either  of  the  recur- 
rent laryngeal  nerves,  or  of  the  trachea  itself,  change  in  the  voice,  dys- 
23noea,  dysphagia,  suffocation,  etc. 

Treatment, — As  goitre  is  generally  benign  during  pregnancy,  we  should 


32  A    TREATISE    ON    OBSTETRICS. 

resort  to  general  measures  and  internal  treatment.  Forbid  tlie  patient  to 
nurse;,  and  give  iodine.  Pastriot  advises  parenchymatous  injections  of 
the  pure  tincture  of  iodine^,  the  iodized  tincture  of  Eichter  (iodide  of 
potassium^  15  grains^,  tincture  of  iodine,  300  grains,  distilled  water,  600 
grains),  or  a  saturated  solution  of  iodide  of  potassium.  But  one  question 
remains  for  consideration.  If  an  acute  or  chronic  goitre  threatens  the 
life  of  the  patient,  shall  we  perform  tracheotomy,  or  induce  labor  ?  The 
facts,  as  thus  far  collected,  do  not  favor  either  proceeding,  but  we  be- 
lieve that  we  have  no  right  to  reject  them.  In  the  presence  of  a  patient 
with  threatening  asphyxia,  the  first  indication  is  to  remove  the  cause,  the 
compression  of  the  trachea,  and  the  disturbance  of  respiration  due  to 
23regnancy.  If  there  is  suppuration,  make  a  free  incision  into  the  thyroid 
abscess.  Some  months  ago,  Tillaux  reported  to  the  Academy  a  case  of 
extirpation  of  the  thyroid  body,  because  of  an  enlargement  which  threat- 
ened the  life  of  the  patient.  Are  we  justified  in  performing  this  opera- 
tion during  pregnancy  ?  In  spite  of  the  success  which  attended  the  opera- 
tion in  the  hand  of  that  skillful  surgeon,  we  should  not  venture  to  resort 
to  it. 

Ulcerations  of  the  Cervix  durii^g  Pregnancy. 

Ulcerations  of  the  cervix  have  been  noted  by  all  physicians  who  have 
examined  the  patients  with  the  speculum.  These  may  assume  the  four 
forms  described  by  Robert,  viz. :  superficial  erosions  or  excoriations,  granu- 
lar or  nodular,  fungoid,  and  callous  (cicatricial  ?)  erosions.  These  different 
forms  may  be  presented  by  simple  or  specific  erosions,,  although  the  cica- 
tricial variety  has  only  been  observed  in  pregnant  women. 

[Throughout  this  section  we  substitute  the  word  erosion  for  ulceration, 
as  being  more  scientific  and  in  accord  with  recent  pathological  terminology. 
Aside  from  lupus  and  chancre,  it  is  questionable  if  a  true  ulcer  is  ever 
found  on  the  cervix.  Further,  many  of  the  instances  which  the  author 
calls  ulceration  are  in  reality  simply  the  eroded  everted  mucous  mem- 
brane of  the  lacerated  cervix.  A  glance  at  Figs.  1  to  7  prove  this. 
—Ed.] 

If,  says  Cazeaux,  we  examine  the  cervix  at  the  end  of  pregnancy,  we 
find  it,  as  a  rule,  of  a  deep  reddish  or  violet  color  (like  wine-lees),  but  with 
this  difference  in  the  primipara  and  multipara:  In  the  former  there  are 
rarely  any  traces  of  erosion,  but  we  commonly  see  around  the  os  externum 
fleshy  nodules,  varying  in  size  from  a  pin's  head  to  a  pea,  which  bleed  at 
the  slightest  touch,  while  in  the  latter,  the  cervix  is  fissured,  the  canal 
presenting  a  series  of  fangoid  projections,  separated  by  clefts;  on  the 
surface  of  some  of  these  projectioiis  are  hypertrojohied  follicles,  while 
others  resemble  flabby  granulations,  being  deprived  of  epithelium  and 
bleeding  easily. 

According  to  Gosselin,  Cazeaux,  and  others,  these  erosions  are  rarely 
•due  to  a  pathological  condition,  but  to  the  passive  congestion  induced  by 


DISEASES    AFFECTING    PEEGNANT   WOMEN. 


33 


pregnancy.  Other  writers  regard  tliem  as  of  great  significance,  and  even 
as  the  principal  cause  of  difficult  labor  and  abortion.  The  latter  influence  is 
ascribed  especially  to  that  variety  of  cervical  erosion  which  is  characterized 
by  a  fungoid  appearance,  Assuring  of  the  cervix  and  tendency  to  bleeding. 
Coffin  and  Kichet  believe  that  the  majority  of  fungoid  erosions  exist  be- 


FiG.  1.— Cervix  of  a  Primipara,  155  days 
BEFORE  Delivery.    {Nieberding.) 


Fig.  3.— Cervix  of  a  Primipara,  41  days 
BEFORE  Delivery.    (Nieberding.) 


Fig.  3.— Cervix  of  a  Primipara, 
36  DAYS  before  Delivery. 
(Nieberding.) 


Fig.  4.-  -Cervix  of  a  I-para, 
31  days  before  delivery. 
(Nieberding.) 


Fig.  0.— Cervix  of  a  II-para, 
27  days  before  delivery. 
(Nieberding.) 


Fig.  6. — Cervix  of  a  I-para,  15  days  before 
Delivery.    (Nieberding.) 


Fig.  7. — Cervix  of  a  Primipara,  4  days  be- 
fore Delivery.    (Nieberding.) 


fore  pregnancy,  or  date  from  a  former  delivery,  and  that  they  exercise 
an  actual  influence  on  the  course  of  pregnancy,  abortion  being  the  usual 
consequence  of  their  presence,  especially  when  the  cervical  canal  is  exten- 
sively involved.  Among  110  women  in  the  latter  half  of  pregnancy  Lieven 
found  more  or  less  severe  erosions  in  32,  10  of  whom  were  primiparge; 
slight  erosion  13;  follicular  7;  mucous  polypi  1;  papillary  erosions  16; 
vegetations  1. 

Vol.  II.— 3. 


34  A    TREATISE    ON    OBSTETRICS. 

In  most  cases  he  found  the  mncous  membrane  at  the  edge  of  the  os  of 
a  reddish  hue,  contrasted  with  the  rest  of  the  portio  vaginalis,  which  is 
bluish,  livid,  deprived  of  epithelium  in  spots,  and  bleeds  at  the  slightest 
touch  (simple  erosion).  He  often  encountered  cervices,  on  the  red,  eroded 
surfaces  of  which  were  innumerable  small,  florid  projections,  the  size  of 
a  pin-head,  distinguished  by  their  bright  color  from  the  surrounding  tis- 
sue (papillary  erosions).  He  claims  that  there  is  no  true  ulceration,  but 
a  simple  ectropion  of  the  mucous  membrane,  due  to  the  dilatation  of  the 
OS  during  pregnancy  with  accompanying  eversion  of  the  mucous  surface, 
the  latter  being  sometimes  so  great  that  the  natural  folds  are  obliterated, 
and  the  mucosa  assumes  a  uniform,  smooth,  glistening  aspect.  He  en- 
deavors to  support  his  views  regarding  the  non-identity  of  erosions  and 
ulcerations  by  reference  to  the  work  of  Euge  and  Veit,  who  have  shown 
that  the  latter  condition  is  characterized  by  loss  of  epithelium,  while  in 
simple  erosion  the  lesion  is  always  covered  by  a  new  layer  of  pavement 
epithelium.  These  authors  affirm  that  erosions  are  produced  by  exten- 
sive proliferation  of  the  epithelium,  accompanied  by  dilatation  and  hy- 
perplasia of  the  glands,  and  the  formation  of  papillse  covered  with  cylin- 
drical epithelium,  ectropion  and  erosion  being  in  their  opinion  two  dis- 
tinct affections,  which  may,  however,  be  associated,  even  while  they  re- 
main distinct. 

Among  28  primiparse,  Nieberding  found  ectropion  in  21,  the  posterior 
lip  being  alone  involved  in  7.  The  os  externum,  instead  of  presenting  its 
usual  rounded  form,  appeared  as  an  irregular  cleft,  from  which  radiated 
fissures  in  the  form  of  a  star,  some  of  which  were  recent  and  bled  readily. 
These,  according  to  Birnbaum  and  himself,  are  due  to  the  distension 
which  affects  the  cervix,  in  common  with  the  lower  uterine  segment,  from 
the  pressure  of  the  foetal  head.  These  were  observed  in  19  out  of  the 
28  cases. 

Lieven  and  Meberding  give  the  following  figures: 

In  60    -j-  parse,  Lieven        found  the  normal  cervix  11  times. 

"  42  "         Nieberding    "        "        "  "      15     " 

"  Ilparse,  Lieven  "        ''        "  "      in  2(3  per  cent. 

"  "      "■  Nieberding   "        "        "  "       "  23     "       " 

"  Illparse,         Lieven  "        "        "  "       "  50     "       '' 

"      "     "  Nieberding    "        '^       "  "       "  50     " 

The  latter  refers  to  the  view  of  Aran,  Bennet,  and  others,  that  erosions 
and  ulcerations  are  due  to  chronic  inflammation  of  the  cervix,  and  that 
they  exercise  an  important  influence  upon  pregnancy,  delivery,  and  the 
puerperal  state,  and  admits  that  they  most  frequently  give  rise  to  uncon- 
trollable vomiting  (Spiegelberg),  hemorrhage,  abortion,  degeneration  of 
the  placenta,  etc,  etc.  Scanzoni  and  Lieven  have  never  observed  such 
effects. 

Treatment. — Whatever  view  we  may  accept,  the  practitioner  is  con 


DISEASES   AFFECTING    PEEGNANT    WOMEN.  35 

fronted  with  the  important  questions — Shall  we  treat  these  lesions  dnring 
pregnancy  ?  and  if  we  do^  AVhat  form  of  caustic  shall  we  use  ?  The  result 
is  doubtful  whether  we  employ  nitrate  of  silver,  caustic  fluids,  or  iron. 
Miscarriage  results  too  often  from  the  treatment,  and  not  from  the  dis- 
ease itself.  We  adopt  Cazeaux's  conclusion:  abstain  from  all  treatment 
as  long  as  the  ulceration  does  not  show  a  marked  tendency  to  involve  a 
great  part  of  the  cervix;  then,  if  you  do  interfere,  bear  in  mind  that  you 
run  the  risk  of  seriously  disturbing  the  pregnancy. 

[Cazeaux's  opinion,  while  true  of  lacerations,  will  not  hold  for  erosions. 
In  case  of  hemorrhage  or  profuse  leucorrhoea  from  erosion,  applications, 
far  from  being  harmful,  are  positively  beneficial.  We  have  yet  to  see 
miscarriage  induced  by  applications  to  an  erosion,  and  we  believe  this  to 
be  the  experience  of  other  gynecologists  and  obstetricians. — Ed.] 


EXPLANATION  OF  PLATES  V  and  VI. 
(From  Munde.) 

1.  Catarrhal  Erosion  of  Nulliparous  Cervix. 

2.  Follicular  Erosion  of  Parous  Cervix,  with.  Fissure. 

3.  Stellate  Laceration,  without  Eversion. 

4.  Stellate  Laceration  with  Eversion  and  Cystic  Hyperplasia. 
6.  Eversion  of  Anterior  Lip  with  Cystic  Hyperplasia. 

6.  Patulous  Os,  without  distinct  External  Fissure. 

7.  Right  Laceration  with  Eversion. 

8.  Bilateral  Laceration,  first  degree,  with  Eversion. 

9.  Bilateral  Laceration,  second  degree,  with  Eversion. 

10.  Bilateral  Laceration,  third  degree,  with  Eversion,  Lips  held  apart 
by  Tenacula. 

11.  Bilateral  Laceration,  third  degree,  with  Eversion,  mostly  cicatrized, 
and  not  ulcerated.  Both  upper  corners  show  fresh  breaking  down  of 
cicatrix. 

12.  Large  Cystic  Hyperplasia  of  Anterior  Lip,  Simulating  Epithelioma. 


PLATE    V. 


5. 


EROSIONS    AND    LACERATIONS    OF    CERVIX. 


.  BENCKE, 


PLATE    VI 


11. 


^ 


t^^^w*H'X- 

hr 

W 

12. 


EROSIONS    AND    LACERATIONS    OF    CERVIX. 


H.  BENCKE, 


CHAPTEE  11. 

DISEASES  OP  PREGNANCY. 

PREGNANCY,  as  we  have  seen,  produces  in  the  entire  economy  im- 
portant and  profound  modifications^,  wliicli  in  their  turn  cause 
functional  disturbances  tliat  find  expression  in  a  series  of  morbid  condi- 
tions, constituting,  properly  speaking,  the  diseases  of  the  pregnant  woman. 
But  these  troubles  do  not  appear  simultaneously  and  invariably,  and, 
while  in  some  cases  they  constitute  a  true  morbid  condition,  in  others  they 
pass,  so  to  speak,  unrecognized.  From  this  point  of  view  we  can  say, 
there  are  as  many  variations  as  there  are  women,  or  even  pregnancies, 
because  it  is  not  rare  to  see  certain  females  pass  through  one  or  two  preg- 
nancies in  a  condition  of  almost  perfect  health,  while  the  succeeding  one 
or  more  pregnancies  are  accompanied  by  profound  malaise.  Moreover, 
it  is  not  uncommon  to  observe  certain  phenomena  appear  at  the  begin- 
ning of  pregnancy,  to  disappear  for  a  time,  and  then  to  reappear  with 
renewed  intensity.  We  shall,  then,  adopting  the  classification  of  Desor- 
meaux  and  Cazeaux,  review  in  turn  the  disturbances  of  digestion,  of  cir- 
culation, respiration,  secretion,  excretion,  locomotion,  and,  finally,  of 
the  sensory  and  intellectual  functions. 

DiSTUEBANCES   OF   DIGESTION. 

As  Pajot  says,  the  functions  of  the  digestive  apparatus  may  be  exag- 
gerated, diminished  or  perverted. 

Exaggeration. — There  are  many  women  whose  digestive  functions  are 
not  only  not  disturbed  by  pregnancy,  but,  on  the  contrary,  seem  to  be  aug- 
mented. Their  appetites  increase,  digestion  is  more  active,  the  nutrition  is 
improved,  and,  as  the  women  themselves  afiirm, pregnancy  seems  to  produce 
in  them  an  unusual  condition  of  health;  but,  it  must  be  acknowledged 
that  this  is  the  exception,  and  that  most  often  the  digestive  functions  are 
either  diminished  or  perverted. 

Anorexia. — This  degree  is  marked  by  loss  of  appetite  and  aversion  for 
food,  which  may  occur  at  the  beginning  of  pregnancy,  as  Avell  as  during  its 
progress  or  at  its  termination;  it  is  usually  most  marked  at  the  beginning. 
This  aversion  may  amount  to  positive  disgust,  in  which  case  the  physician 
is  often  extremely  embarrassed  in  the  presence  of  the,  so  to  speak,  passive 
resistance  of  the  patient  to  every  sort  of  food.  Food  hot  or  cold,  vegeta- 
bles, fruits,  nothing  is  acceptable,  even  fluids  being  rejected,  so  that  it  is 
very  difficult  to  nourish  the  patients.     We  are  only  too  fortunate  if  we 


38  A   TREATISE    OJST    OBSTETRICS. 

have  to  deal  only  witli  anorexia  pure  and  simple,  and  if  it  aoes  not  reach 
tlie  third  stage. 

Aversion  for  Food.—lw  this  case  we  meet  Avith  numberless  difficulties, 
which  vary  with  each  individual.  A  woman  thus  affected, who  could,before, 
tolerate  only  red  wine,  now  rejects  it  entirely;  anotlier,  who  only  cared  for 
meat  of  a  white  color,  can  not  endare  even  the  sight  of  it.  A  patient  who 
could  only  eat  meat  that  was  well  done,  does  not  fancy  it  unless  it  is  rare; 
another,  who  liked  vegetables,  regards  them  with  horror,  etc.  Thus  nume- 
rous are  the  difficulties  which  are  sometimes  encountered  by  the  physician 
in  the  presence  of  a  positive  aversion  for  every  sort  of  food.  All  treatment 
fails,  as  a  rule,  when  directed  towards  this  condition,  which  may  persist  for 
some  time,  but  ordinarily  yields  spontaneously,  as  the  pregnancy  advances. 
This  phenomenon,  in  fact,  is  usually  produced  during  the  first  tAVO  or 
three  months,  and  belongs  among  what  are  known  as  the  sympathetic 
troubles  of  pregnancy.  Sometimes,  however,  this  condition  evidently 
depends  upon  a  dyspeptic  state  in  the  Avoman,  and  then  it  yields  to  slight 
purgatives,  as  rhubarb,  magnesia,  and  some  bitters,  as  quassia;  but  that 
which  usually  succeeds  the  best  is  alcohol  in  small  doses.  In  other  in- 
stances, digestion  is  painful  or  retarded,  gas  is  formed  in  the  stomach, 
there  is  distension  of  the  abdomen,  and  drowsiness.  We  have  found  of 
value  in  these  cases  black  coffee  after  meals,  and  especially  small  doses  of 
alcoholics  (brandy,  Kirsch,  cliampagne)  mixed  with  Seltzer  or  other  alka- 
line mineral  Avaters,  also  pepsin. 

DlSTURBAlSiCE   AND    PeEA^ERSION    OF   THE    DIGESTIVE   FuTSTCTIOlSrS. 

The  perversion  consists  in  the  existence  of  Avhat  is  called  pica,  malacia, 
or  the  "  longings  "  of  pregnant  women.  These,  again,  present  themselves 
under  every  form,  being  represented  by  the  capricious  appetite  of  Avomen 
for  the  most  absurd  and  disgusting  things.  We  must,  up  to  a  certain 
limit,  pay  respect  to  these  caprices  of  the  stomach,  so  far,  at  least,  as  they 
are  not  directed  toAvards  injurious  articles.  Chalk,  charcoal,  ashes,  de- 
cayed and  acid  fruit,  "high^'  meat,  are  the  usual  objects  desired.  This 
longing  is  not  seldom  unaccompanied  by  other  phenomena,  such  as  gas- 
tralgia,  cramps  in  the  stomach,  and  acidity.  Among  the  troubles  to  be 
mentioned  is  one  that  is  frequent  and  is  borne  very  ill  by  women — a  sen- 
sation of  heat,  or  burning,  extending  from  the  pharynx  to  the  stomach, 
and  constituting  the  pyrosis  of  pregnant  Avomen.  Alone  or  accompanied 
by  another  phenomenon,  Avhich  we  shall  study  later  (ptyalism),  it  gener- 
ally persists  for  a  long  time  and  resists  all  treatment.  HoAvever,  good  re- 
sults have  been  obtained  Avitli  alkaline  mineral  waters,  bismuth,  charcoal, 
ice,  antispasmodics,  etc. 

Vomiting. 

The  most  common  digestive  trouble  is  nausea  and  A^omiting.     Although 


DISEASES    OF   PREGNANCY.  39 

the  latter  is  generally  borne  comparatively  well  by  tile  patient,  in  some 
cases  it  becomes  so  severe  as  to  be  uncontrollable,  and  thus  to  seriously 
endanger  life.  Sometimes  nausea  alone  is  present,  but  this  is  rare. 
Vomiting  is  so  common  in  pregnant  women  that,  in  the  majority  of  cases, 
it  is  an  almost  certain  sign  of  pregnancy. 

a.  Simple  Vomiting. — Vomiting  usually  appears  at  the  beginning  of 
pregnancy,  sometimes  in  the  first  days;  at  other  times  it  does  not  occur 
until  later,  at  the  second,  third,  or  fourth  month.  As  a  rule,  it  begins 
at  the  first  month,  continues  until  the  fourth,  and  then  disappears,  until 
the  end  of  pregnancy,  when  it  sometimes  reappears.  Although  regarded 
by  most  writers  as  due  to  the  impression  made  upon  the  entire  economy 
by  the  enlargement  of  the  uterus,  it  has  been  regarded  by  others  as  char- 
acteristic of  certain  uterine  lesions,  especially  erosions  of  the  cervix 
(Bennett);  but  these  erosions,  although  frequent,  are  not  present  in  all 
women  who  vomit,  and  moreover,  how  do  we  explain  its  disappearance, 
at  the  end  of  a  few  months  of  pregnancy,  and  that  too,  spontaneously, 
often  even  suddenly  ?  "When  it  reappears  at  the  end  of  pregnancy,  it  is 
usually  attributed  to  a  disturbance  of  the  stomach,  resulting  from  en- 
largement of  the  uterus.  Vomiting  usually  occurs  in  the  morning  on 
changing  the  position  from  the  horizontal  to  the  vertical.  The  vomited 
matter  consists  of  glairy  mucus,  fluids  more  or  less  watery,  which,  after 
a  certain  time,  are  accompanied  by  bile.  Sometimes  it  is  very  easj'',  at 
others  it  is  accompanied  by  severe  straining,  and  continues  thus  every 
day,  sometimes  once,  and  again  at  frequent  intervals.  At  other  times 
the  women  do  not  vomit  upon  rising,  but  after  each  meal,  the  vomited 
matter  consisting  of  food;  or  vomiting  occurs  during  the  meal,  or  three 
or  four  hours  after,  either  from  some  unknown  cause,  or  from  fatigue, 
emotion,  etc.  In  some  cases  it  takes  place  easily  and  suddenly,  in  others, 
on  the  contrary,  it  is  preceded  for  some  time  by  a  condition  of  nausea, 
more  fatiguing  perhaps  than  the  vomiting  itself.  Sometimes  it  is  pain- 
less, sometimes,  on  the  other  hand,  it  is  accompanied  by  severe  pains  in 
the  epigastrium  and  the  entire  abdomen.  As  a  rule,  women  bear  it  very 
well,  but  sometimes,  when  it  is  repeated  too  often,  it  causes  disturbance 
of  nutrition,  leading  to  marked  emaciation,  and  a  condition  of  weakness 
and  general  fatigue  which  is  extremely  annoying.  Although  it  some- 
times resists  every  method  of  treatment,  it  occasionally  disappears  sud- 
denly, either  in  consequence  of  a  lively  emotion,  as  in  a  case  cited  by 
Cazeaux,  or  because  the  morbid  reflex  impulse  is  transferred  to  another 
organ.  I  once  saw  vomiting  cease  on  the  appearance  of  a  slight  diar- 
rhoea, which  lasted  two  days.  It  usually  has  no  influence  upon  the  course 
of  the  pregnancy,  remains  bearable,  and  causes  the  patients  annoyance 
and  malaise,  rather  than  actual  suffering.  It  is  not  the  same  in  other 
cases  (unhappily  too  frequent),  in  which  it  assumes  the  character  of 

b.  Uncontrollable  Vomiting. — We  may,  with  Dubois  and  the  majority 


40  A   TEEATISE    ON    OBSTETEICS. 

of  writers,  regard  vomiting  as  uncontrollable  "  whenever  it  afEects  seri- 
ously tlie  Ileal th  of  the  woman,  and  resists  the  judicious  use  of  a  certain 
number  of  remedies."  Uncontrollable  vomiting  is  not  extremely  rare, 
because  Dubois  himself  saw  20  fatal  cases;  Delbet  had  collected  62  cases 
in  1854,  Grueniot  118  in  1863,  and  since  then  the  number  has  greatly 
increased.     We  may,  with  Dubois  and  Gueniot,  consider  three  stages. 

First  Stage. — The  onset  is  rarely  abrupt;  more  usually,  the  vomiting 
gradually  becomes  uncontrollable,  succeeding  insensibly  to  the  ordinary 
vomiting  at  the  outset  of  pregnancy;  but  this  gradual  transition  is  not 
always  present,  and  we  often  see  within  a  short  time  the  vomiting  assume 
an  exceptionally  grave  character,  and  rapidly  become  uncontrollable.  It 
usually  begins  during  the  early  months  of  pregnancy,  rarely  in  the  latter 
half,  judging  at  least  by  Gueniot's  statistics,  in  which  he  notes  the  fact 
that,  among  43  cases,  38  occurred  before  the  third  month.  Uncontrollable 
vomiting  does  not  present  any  well-marked  characteristic  at  the  outset; 
it  usually  announces  itself  by  a  condition  of  almost  constant  nausea,  and 
by  its  violence,  which  becomes  more  and  more  alarming.  It  takes  place 
not  only  in  the  morning  and  after  meals,  but  in  the  interval,  and  without 
provocation,  that  is  to  say,  it  is  almost  incessant.  It  is  caused  by  the 
smallest  amount  of  food  or  drink;  the  vomited  matter  consists  of  glairy 
mucus,  bile,  or  food,  according  as  the  stomach  is  full  or  empty;  some- 
times pure  bile  is  vomited,  or  there  may  be  streaks  of  blood.  It  is  in  some 
instances  very  painful,  and  is  accompanied  by  violent  straining,  fatigue, 
and  gastric  pains,  while  in  others  there  is  not  much  disturbance;  in  other 
cases,  there  are  slight  remissions,  of  which  we  may  take  advantage  to 
give  the  patient  a  little  nourishment,  or,  on  the  other  hand,  in  spite  of 
its  continuance,  it  is  accompanied  by  caprices  or  vagaries  on  the  part  of 
the  stomach,  which  make  it  possible  for  the  patients  to  tolei^ate  the  most 
indigestible  things.  (Sandras.)  The  patients  are  then  condemned  to 
almost  complete  abstinence,  which  is  shown  by  their  anxious  look,  weari- 
ness, pain,  and  marked  emaciation,  accompanied  by  a  complete  change 
in  their  features  and  loss  of  strength — in  short,  a  very  pronounced  moral 
and  physical  depression.  It  is  sometimes  complicated  by  ptyalism  and 
diarrhoea,  which  may  eitiier  coincide  or  alternate.  (Haigton. )  This 
stage  is  characterized  by  the  entire  absence  of  fever,  or  if  this  is  present, 
it  is  of  short  duration  and  slight  intensity.  A  slight  evening  rise  indicates 
the  transition  to  the 

Second  Stage. — This  stage  succeeds  the  first  insensibly,  and  almost  with- 
out transition.  It  is  marked  especially  by  the  aggravation  of  all  the  ])he- 
nomena  described  in  the  first  stage,  but  above  all,  by  the  fever,  which  be- 
comes continuous,  and  more  and  more  marked.  The  skin  becomes  hot 
and  dry,  except  the  extremities,  which  are  cold,  and  are  covered  with 
clammy  perspiration;  vomiting  is  incessant,  nothing,  not  even  pure  water 


DISEASES    OF    PEEGNANCY,  41 

being  retained.  The  throat  and  month  become  dry,  sordes  appear  on 
the  teeth,  the  tongue  is  dry  and  red,  the  breath  fetid,  there  is  excessive 
thirst,  the  urine  becomes  scanty,  high  colored,  and  offensive,  and  diarrha-a 
is  regularly  present.  Gneniot  describes,  moreover,  violent  j^iiins  in  the 
head,  the  pit  of  the  stomach,  and  the  hypochondriac  regions;  there  is 
frightful  emaciation,  and  such  feebleness  that  attacks  of  fainting  or  syncojje 
occur  incessantly.  In  some  cases  (unhappily  too  rare),  there  still  occur 
remissions,  during  which  the  patients  can  retain  a  little  nourishment. 

Third  Stage. — It  is  a  curious  fact  that  the  vomiting  diminishes  and 
even  ceases  entirely,  while  the  fever  increases  still  more,  and  characteris- 
tic cerebral  and  sensory  disturbances  appear,  delirium,  coma,  and  hallu- 
cinations. The  attacks  of  fainting  and  syncope  return  on  making  the 
slightest  movement,  the  fever  continues,  the  pulse  becomes  feeble  and 
almost  insensible,  varying  from  120  to  140,  and  coma  appears,  to  con- 
clude the  scene. 

G'ourse  and  Duration. — It  is  a  remarkable  fact  that  there  are  frequent, 
more  or  less  complete,  remissions,  especially  during  the  first  and  second 
stages.  Among  the  complications  Gueniot  mentions  ptyalism,  diarrhcea, 
syncope,  thrush,  gangrene  of  the  mouth,  and  pulmonary  tuberculosis; 
as  secondary  complications,  hysteria,  epileptiform  convulsions,  albu- 
minuria and  eclampsia,  atresia  uteri,  and  cancer  of  the  stomach  are 
noted.  The  same  writer  reports  46  deaths  among  118  cases,  while 
Delbet  mentions  30  fatal  cases  out  of  a  total  of  62. 

Patliological  Anatomy. — This  affords  only  imperfect  indications, 
because  the  autopsies  are  often  completely  negative,  or  reveal  lesions  of 
very  diverse  character.  There  has  been  found  atrophy  of  the  muscular 
system  and  of  the  adipose  tissue,  decrease  in  the  size  of  the  intestine,  with 
occasionally  slight  softening  and  injection  of  the  mucous  membrane  of 
the  stomach.     Various  other  non-characteristic  lesions  have  been  noted. 

Causes. — Pregnancy  must  be  mentioned  as  the  essential  predisposing 
cause,  which  acts  through  the  organic  and  functional  modifications  that 
it  impresses  upon  the  uterus,  as  though  by  the  more  or  less  marked 
general  stimulation  of  the  nervous  system;  but,  to  this  general  predis- 
posing cause  we  must  add  a  nervous  disposition,  multiparity,  inflamma- 
tion of  the  uterine  tissue  or  ovum,  erosions,  atresia,  or  hypersesthesia  of 
the  OS  externum,  and  displacements  of  the  uterus.  Finally,  in  addition 
to  these  causes,  which  bear  an  intimate  relation  to  pregnancy,  vomiting 
occurs,  due  to  some  functional  or  organic  gastric  trouble. 

Diagnosis. — It  would  seem  at  first  sight  as  if  the  diagnosis  ought  to  be 
extremely  easy.  However,  Gueniot  has  rightly  shown  that  it  includes 
three  very  distinct  factors,  viz.  :  1st.  The  diagnosis  of  pregnancy;  2d. 
The  diagnosis  of  the  adjuvant  or  determining  cause  of  the  vomiting;  3d. 
The  differential  diagnosis  between  obstinate  vomiting  due  to  pregnancy. 


42  A  TREATISE  ON"  OBSTETRICS. 

and  that  due  to  some  other  cause  independent  of  gestation.  Errors  are 
most  likely  to  be  made  in  the  last  instance. 

Prognous. — This  is  exceedingly  grave,  above  all  after  the  beginning 
of  the  second  stage,  while  in  the  third,  death  is  almost  inevitable.  The 
death  of  the  foetus,  or  spontaneous  abortion,  is  generally  favorable,  but  it 
would  be  a  mistake  to  infer  that  all  danger  has  disappeared  in  conse- 
quence of  such  an  event. 

Treatment. — This  consists  in  attention  to  diet  and  hygiene,  in  strictly 
medical  as  well  as  surgical  and  obstetrical  treatment. 

1.  Diet  and  Hygiene. — Since  uncontrollable  vomiting  rarely  begins 
abruptly,  and  more  usually  succeeds  the  light  form,  we  shall  do  well  at 
the  outset  to  establish  a  rigid  diet,  excluding  heavy  and  indigestible  food, 
all  forms  of  stimulants,  especially  alcoholic,  and  recommending  the  use 
of  white  meats,  jellies,  milk-diet,  in  short,  easily-digested  articles.  The 
physician  can  not,  however,  lay  down  absolute  rules,  but  must  consider 
the  caprices  of  the  stomach.  We  must  vary  the  diet  as  much  as  possible, 
and,  if  the  stomach  succeeds  in  tolerating  any  fluid  or  solid  article  of 
nourishment,  we  must  not  spoil  our  chances  of  success  by  insisting  on  a 
prolonged  use  of  it,  but  should  combine  it  with  others.  Increase  the 
nourishment,  very  gradually,  since  relapses  are  frequent.  If  they  occur, 
try  something  else,  varying  the  food  constantly,  as  the  main  object  is 
to  gain  time;  vomiting  often  ceases  spontaneously  after  an  interval,  as  the 
pregnancy  advances. 

Medical  Treatment. — The  very  multiplicity  of  the  remedies  suggested 
by  different  writers,  proves  their  small  value  and  uncertain  action.  The 
idea  is  to  resort  to  rectal  alimentation,  but  this  is  uncertain,  because  the 
enemata  soon  cause  diarrhoea,  a  condition  often  associated,  as  we' have 
seen,  with  uncontrollable  vomiting.  Raw  meat  is  often  repugnant,  and 
prolonged  rest  on  the  back,  sea  voyages  and  walking,  are  not  easily 
recommended  to  women  in  this  condition.  The  oldest  form  of  treat- 
ment is  the  antiphlogistic  (venesection,  leeches,  etc.),  but  the  results 
have  been  contradictory.  Some  physicians  have  applied  leeches  directly 
to  the  cervix  uteri  with  success.  Local  revulsives,  sinapisms,  blisters,  etc., 
as  well  as  purgatives  and  emetics,  have  sometimes  succeeded,  sometimes 
failed;  the  same  may  be  said  of  acids,  alkalies,  aromatics,  and  antispas- 
modics. Opium,  especially,  seems  to  have  a  decided  action,  whether 
given  by  the  mouth  or  hypodermatically  (the  latter  method  being  prefer- 
able), while  applications  of  belladonna  to  the  cervix  have  been  successful. 
Hydrocyanic  acid,  tincture  of  iodine,  iodide  and  bromide  of  potassium, 
oxalate  of  cerium  (used  by  Simpson  in  45-grain  doses),  tincture  of  nux 
vomica,  calomel  in  small  doses,  pejosin,  cold,  alcohol  (especially  Kirsch, 
brandy,  and  iced  champagne),  and  ice  internally  and  externally,  may  be 
mentioned  as  empirical  remedies.     Ether-spray,  applied  to  the  epigastrium 


DISEASES    OF   PREGNANCY.  43 

and  along  the  spinal  column^  has  recently  been  recommended,  also 
electricity  and  subcutaneous  injections  of  ether.  All  of  the  foregoing 
remedies  have  succeeded  in  some  cases,  but  as  a  rule  they  have  failed. 

[Other  remedies  which  we  have  found  in  certain  cases  of  value,  are: 
The  hydrate  of  chloral,  in  grain  doses  repeated  every  few  minutes,  till  15 
lo  20  grains  have  been  taken,  and  associated  for  a  time  with  the  re- 
cumbent position.  The  hydrochlorate  of  cocaine,  in  ^  grain  doses,  has 
twice  given  us  good  results,  but  in  other  instances  failed.  Very  hot 
water  sipped  slowly  will  often  ansv^er. — Ed.] 

There  remains  then, 

3d.  Surgical  Treatment. — This  consists  in  cauterization  of  the  cervix 
uteri,  a  procedure  originally  suggested  by  Bennet,  and  used  successfully 
by  various  authorities.  Bennet  confines  the  cauterization  with  nitrate  of 
silver  or  iron  to  the  region  of  the  os  externum,  with  the  view  of  checking 
the  vomiting  without  interrupting  the  pregnancy,  while  Giordano,  on 
the  contrary,  aims  at  terminaiing  it,  and  hence  applies  the  caustic  as 
high  up  as  the  os  internum.  Copeman  has  been  successful  in  the  em- 
ployment of  digital  dilatation  of  the  cervix.  "We  have  never  obtained 
any  results  with  this  treatment  unless  it  caused  abortion.  Moreau  has 
cured  patients  by  replacing  the  uterus  when  it  was  malposed.  [Cope- 
man's  method  is  of  greater  utility  than  "the  reader  would  judge  from  the 
author's  statement.  Obstetricians  in  this  country,  who  have  resorted  to  it, 
report  numerous  successes,  even  in  desperate  cases.  Either  the  finger  or 
the  steel-branched  dilator  may  be  used,  a  necessary  precaution 
being  to  pass  neither  beyond  the  internal  os.  Where  miscarriage  results, 
the  chances  are  it  is  because  this  precaution  has  been  neglected.  Of  the 
advocates  of  this  method  in  this  country,  we  may  mention  Goodell, 
Munde,  "Wylie.  The  latter  claims  for  it  precedence  over  all  other 
methods. — Ed.] 

4th.  Ohstetrical  Treatment. — This  consists  in  the  induction  of 
abortion,  in  preference  to  premature  labor.  If  the  child  is  viable  (after 
the  seventh  month),  we  must  act  at  once  in  the  interests  of  both  the 
mother  and  the  child.  Simmond  (1813),  was  the  first  to  practice  this 
measure.  Since  then  a  large  number  of  successful  cases  have  been 
recorded,  in  fact  two-thirds  of  the  cures  are  obtained  in  this  way.  The 
determination  of  the  proper  time  at  which  to  interfere  is  one  of  the 
most  delicate  questions  in  our  profession.  Dubois  affirms  that  inter- 
ference is  most  proper  during  the  second  stage,  when  the  following 
conditions  are  present:  Incessant  vomiting  of  all  ingesta,  even  a  small 
quantity  of  water,  marked  feebleness  and  emaciation,  preventing  the 
patient  from  making  the  slightest  exertion,  attacks  of  syncope,  following 
the  least  movement  or  excitement,  profound  alteration  of  the  features, 
marked  continued  fever,  extreme  acidity  of  the  breath,  and,  finally,  the 
failure  of  every  applied  remedy. 


44  A    TREATISE    OlS"   OBSTETRICS. 

[In  onr  opinion  it  is  not  good  practice  to  wait  for  tlie  appearance  of 
the  symptoms  of  the  second  stage  before  resorting  to  the  induction  of 
abortion,  for  then  we  simply  add  the  additional  shock  of  labor  to  a 
constitution  already  strained  to  the  utmost  by  the  vomiting.  In  case 
the  usual  remedies  by  the  mouth,  associated  with  rectal  enemata  of 
peptonized  milk  (and  these  will  not  induce  diarrhoea  if  cold  water 
enemata  precede  each  nutrient  enema),  and  also  with  dilatation,  do  not 
succeed  in  releasing  the  woman  from  the  vomiting,  which  if  it  continues 
will  kill  her,  then,  before  exhaustion  sets  in,  miscarriage  or  premature 
labor  should  be  induced.  A  consultation  should  always  precede  any 
operation  of  the  kind. — Ed.] 

Leveu  believes  that  we  can  prevent  the  development  of  uncontrollable 
vomiting,  and  that  we  can  stop  it  after  it  has  begun.  The  following 
are  his  views,  which  we  are  far  from  adopting  in  every  respect:  Dys- 
pepsia, loss  of  appetite  and  vomiting  begin  with  pregnancy.  The 
woman  craves  the  most  indigestible  articles,  such  as  can  only  aggravate 
the  existing  dyspepsia,  while  she  feels  an  aversion  for  solid  nourishment 
(meat,  fish,  etc.),  which  the  stomach  requires  in  order  to  remain  in 
health.  The  same  may  be  said  of  her  desire  for  stimulants.  Physicians 
have  habitually  humored,  rather  than  checked,  these  tendencies,  think- 
ing that  the  vomiting  would  cease  spontaneously  as  the  pregnancy 
advanced.  On  the  contrary,  the  stomach,  after  having  been  injured  by 
improper  diet,  becomes  so  irritable  that  it  will  not  tolerate  nourishing 
food,  and  the  woman  really  dies  of  hunger.  If  the  physician  recognizes 
the  condition  as  dyspepsia,  and  begins  his  treatment  at  the  outset  of 
pregnancy,  the  result  will  be  different.  For  several  days  nothing  should 
be  given  but  liquid  nourishment  (not  soups,  which  are  irritating,  but 
milk),  while  hot  applications  and  sinapisms  are  used  over  the  region  of 
the  stomach,  phosphate  of  lime,  or  bismuth,  being  administered  inter- 
nally. Milk  will  be  tolerated  for  a  few  weeks,  when  the  stomach  will 
gradually  be  able  to  retain  solid  food. 

We  can  not  accept  these  conclusions,  because  they  do  not  explain  why 
vomiting  should  suddenly  cease  after  simple  dilatation  of  the  cervix. 

Constipation. 

Constipation  is  the  rule  in  pregnant  women,  and  sometimes  resists 
every  remedy  employed  to  relieve  it.  It  has  been  mentioned  by  all 
writers  from  the  earliest  times.  While  in  the  majority  of  cases  it  may 
give  rise  simply  to  anorexia,  disturbances  of  digestion,  and  pains  in  the 
back  and  abdomen,  in  some  instances  it  occasions  more  serious  manifes- 
tations. Aside  from  the  increased  straining  of  the  woman  in  her  efforts 
to  expel  the   hardened  faeces,  it  may  cause  pelvic  congestion,  as  shown 


DISEASES    OF  PREGNANCY.  45 

by  a  feeling  of  tension,  weiglit,  fullness,  by  the  presence  of  hemorrhoids, 
etc.;  it  may  even  produce  uterine  contractions  and  abortion,  as  Avas 
noted  by  Hippocrates  and  other  ancient  writers.  We  must  accordingly 
oppose  it  most  carefully,  by  the  use  of  proper  diet,  enemata,  and  mild 
purgatives. 

DiARRHCEA. 

This  is  not  so  rare  as  we  may  think.  It  sometimes  alternates  with 
constipation,  or  it  may  be  the  patient's  habitual  condition,  and,  though 
usually  harmless,  it  may,  in  some  instances,  assume  a  grave  character, 
resembling  to  some  extent  uncontrollable  vomiting,  which  it  may 
furthermore  often  complicate.  Abortion  and  premature  labor  may  occur 
in  consequence.  "We  have  obtained  excellent  results  in  a  case  of  obstinate 
diarrhoea,  by  giving  night  and  morning  a  pill  containing  gr.  ^  of 
nitrate  of  silver.  An  enema  night  and  morning,  containing  fifteen  or 
twenty  drops  of  laudanum,  is  usually  sufficient. 

Disturbances  of  Eespiration. 

We  can  not  insist  too  strongly  on  the  fact  that  during  pregnancy 
there  is  a  larger  quantity  of  blood  in  circulation,  and  that  as  a  result  the 
pulmonary  circulation  is  increased.  It  is  not  even  necessary  that  a 
cardiac  lesion  should  be  present  in  order  to  cause  capillary  bronchitis 
and  pulmonary  hemorrhage  which  rapidly  becomes  dangerous.  We 
have  observed  two  cases  in  which,  unknown  females  were  brought  to  the 
clinic  in  a  condition  of  asphyxia  or  coma,  similar  to  the  coma  which 
succeeds  an  attack  of  eclampsia.  They  perished,  in  spite  of  venesection, 
and  an  autopsy  in  both  cases  revealed  the  presence  of  pulmonary  conges- 
tion and  hemorrhage,  without  heart-disease.  Peter's  observations 
have  shown  that,  aside  from  disease,  the  lungs  in  pregnancy  are  warmer 
than  in  the  non-pregnant  state,  the  increased  heat  being  due  directly 
to  the  greater  supply  of  blood.  It  is  not  rare  to  witness  a  proof  of  the 
pulmonary  congestion  in  the  haemoptysis  which  appears  after  delivery. 

Disturbances  of  the  Circulation. 

loifluence  of  Pregnancy  on  Diseases  of  the  Heart. — By  reference  to 
the  previous  remarks  concerning  the  modifications  in  the  circulatory 
system  produced  by  pregnancy,  the  reader  will  see  that,  aside  from  the 
hypertrophy  of  the  uterine  vessels,  the  changes  in  the  circulation  may 
consist  in:  1st.  Increase  of  the  total  quantity  of  the  blood.  2d.  Alter- 
ation of  the  constituent  parts  of  the  blood,  as  shown  by  the  increase  of 
water,  white  corpuscles,  and  by  the  diminution  in  the  number  of  red 
discs,  albumin,  and  iron,  as  well  as  the  fibrin  (at  least  early  in  preg- 
nancy).    There   exists   in    the   pregnant  woman,   therefore,  a  peculiar 


46  A    TEEATISE    OlSr    OBSTETRICS. 

condition,  neither  plethora  nor  anfemia,  characterized  by  cardiac  hyper- 
trophy and  mnrmurs,  dyspnoea,  oppression,  and  a  tendency  to  congestion 
of  the  viscera,  especially  the  Inngs.  Peter  believes  that  the  amount  of 
blood  increases  during  pregnancy,  simply  because  of  the  existence  of 
this  condition,  and  the  needs  of  the  foetus,  so  that  the  hemorrhage  after 
delivery  is  physiologically  necessary,  in  order  to  relieve  the  woman  of 
the  extra  quantity  of  blood.  Hypertroj)hy  of  the  left  side  of  the  heart 
is  a  purely  mechanical  result  of  the  increased  work,  caused  by  the  high 
aortic  tension,  from  the  direct  pressure  of  the  uterus  (Eaynaud),  or  the 
additional  foetal  circulation.  This  hypertrophy  is  only  temporary, 
disappearing  rapidly  and  completely  after  delivery.  But  it  may  persist 
in  some  instances,  and  become  permanent,  increasing  with  each  subse- 
quent pregnancy,  and  culminate  in  a  true  cardiac  affection,  which,  in 
its  turn,  under  the  influence  of  pregnancy,  becomes  the  starting-point 
for  a  group  of  symptoms,  now  known  as  the  cardiac  symptoms  of 
pregnancy  {accidents  gravido-cardiaques). 

Pregnancy  is  only  one  of  the  causes  which  hasten  the  progress  of 
heart-disease,  the  phenomena  of  which  develop  more  or  less  rapidly 
during  pregnancy  and  under  its  influence.  This  influence  may  be 
transient,  when  the  valvular  lesion  or  myocarditis  is  not  aggravated,  but 
repeated  pregnancies  do  cause  aggravation  of  them.  Porak  shows  that 
on  the  whole,  cardiac  lesions,  although  not  infrequent  after  delivery 
and  during  the  puerperium,  are  rare  during  pregnancy.  Opinions 
difl'er' regarding  the  presence  of  cardiac  hypertrophy  in  pregnancy,  some 
authorities  believing  in  the  existence  of  hypertrophy,  others  in  dilatation, 
while  others  affirm  the  co-existence  of  both  conditions.  Letulle  arrives 
at  the  following  conclusions:  Physiological  hypertrophy  of  the  heart 
during  pregnancy  is  not  constant,  the  apparent  enlargement  of  the  organ 
being  sometimes  due  to  its  elevation  by  the  diaphragm.  The  presence 
of  temporary  dilatation  is  proved  by  the  jugular  reflux,  cardiac  and 
venous  murmurs,  and  anaemia;  some  of  these  symptoms  disappear  after 
delivery.  The  dilatation  is  to  be  referred  to  the  increased  tension  in 
the  right  ventricle,  as  well  as  to  obstruction  from  pulmonary  trouble; 
in  this  case,  hypertrophy  and  dilatation  may  co-exist,  when  errors  of 
diagnosis  are  easy,  especially  if  the  heart  is  elevated  by  the  diaj)hragm. 
Porak  found  that  the  weight  of  the  heart  in  women  dying  soon  after 
delivery  varied  from  8  to  10.9  ounces,  while  Letulle  states  that  the 
weight  varies  from  8  to  10  ounces,  the  normal  organ  varying  from  6.9 
to  7.2  ounces.  Cohnstein  found  hypertrophy  of  the  left  ventricle  in 
ten  cases  out  of  tAventy,  dilatation  in  eight,  myocarditis  in  eight  and 
aortic  stenosis  in  five.  We  do  not  see  how  Porak  can  arrive  at  this  con- 
clusion. Idiopathic  hypertrophy  of  the  heart  must  be  rare,  but  it  is 
not  so  in  regard  to  actual  cardiac  lesions,  and  the  persistence  of  the 
hypertrophy  after  repeated  pregnancies  is  intimately  related   to  such 


DISEASES    OF   PREGNAI^CY.  47 

lesions.  Degeneration  of  the  myocardinm,  leading  to  rupture  of  the 
heart,  has  been  observed,  especially  during  the  puerperal  state. 

Endocardial  Lesions. — Endocarditis  often  occurs  during  pregnancy, 
and  may  be  acute,  sub-acute,  or  chronic.  The  acute  form  may  be  of 
the  typhoid  or  pysemic  variety,  and  is  marked  by  the  presence  of 
exuberant  vegetations  on  the  endocardium,  resulting  in  emboli  {due  to 
coagulation  or  the  detachment  of  bits  of  vegetations),  the  plugging  of 
vessels  and  hemiplegia.  However,  acute  endocarditis  during  pregnancy 
is  rare. 

S'uh-acute  and  Chronic  Endocarditis.  This  is  comparatively  frequent, 
and  may  succeed  the  acute  form.  Valvular  lesions  are  many,  and 
their  location  different,  but  the  mitral  valves  are  most  commonly 
affected,  either  alone  or  in  common  with  the  others.  Porak  fouiid 
mitral  insufficiency  in  twenty-two  cases,,  stenosis  in  thirteen,  both  condi- 
tions being  present  in  twenty-two,  making  fifty-seven  in  all;  the  aoi'tic 
valves  were  affected  in  thirteen  cases,  insufficiency  being  noted  nine 
times  and  stenosis  twice,  both  being  present  in  two  cases.  In  twenty- 
two  other  cases,  the  two  valves  were  simultaneously  involved.  These 
lesions  may  be  well  borne  by  the  women,  but  cardiac  troubles  may  ari^e, 
presenting,  according  to  Porak,  four  variations,  viz.:  1st.  There  may 
be  disturbance  of  the  heart's  innervation,  leading  to  palpitation  of  a 
more  or  less  irregular  character,  which  increases  with  the  progress  of 
the  pregnancy  and  is  accompanied  by  dyspnoea,  attacks  of  oppression, 
generally  transient,  but  sometimes  very  violent  and  attended  with  ver- 
tigo, head-ache,  precordial  pains,  but  no  physical  signs  pointing  to 
the  lungs.  More  usually  the  woman  is  disturbed  and  oppressed,  but  has 
no  attacks  except  on  making  strong  efforts  or  movements.  She  com- 
plains of  short  breath  rather  than  palpitation  and  of  syncope;  in  time 
the  dyspnoea  increases,  so  that  the  patient  is  obliged  to  remain  in  bed 
in  a  semi-recumbent  attitude,  every  movement  being  followed  by  palpi- 
tation and  syncope,  and  increasing  the  dyspnoea.  Most  often  the 
condition  is  complicated  by  pulmonary  congestion  and  oedema,  which 
increases  as  the  pregnancy  advances,  and  may  be  accompanied  by 
haemoptysis,  apoplexy,  epistaxis,  hematemesis,  etc.,  troubles  which  assume 
an  exceptional  gravity.  A  third  variety  is  asystole,  which  may  be 
more  or  less  marked,  and  may  cause  greater  or  less  disturbances  of 
.the  general  circulation  leading  to  ascites  hydro-thorax  secondary 
affections  of  the  liver  and  kidneys,  etc.  Emboli  may  occur  in  a  fourth 
variety,  which,  when  carried  to  the  liver,  kidneys,  lungs,  or  bram,  will 
cause  various  symptoms.  All  the  foregoing  phenomena  may  be  con- 
founded, united,  or  may  appear  more  or  less  simultaneously  and 
perfectly,  according  to  the  accessory  circumstances  and  causes.  All 
heart-lesions  do  not  present  the  same  frequency  and  gravity.  TJie 
mitral  lesion  is  the  most  common;  next  to  this,  pulmonary  congestion 


48 


A   TEEATISE    OX    OBSTETRICS. 


and  oedema.  Affections  of  the  aortic  ralres  are  mucli  more  rare,  are 
generally  better  tolerated^  and  give  rise  to  few  symptoms;  finally^ 
lesions  involving  the  right  side  of  the  heart  are  still  more  grave,  since 
they  lead  very  rapidly  to  asystole  and  its  con  sequences. 

As  a  rule,  the  cardiac  troubles  of  pregnancy  do  not  acquire  the 
maximum  intensity  until  after  the  first  congestion.  Though  borne 
pretty  well  at  first,  they  reappear  with  more  intensity  at  each  new  preg- 
nancy, until  the  storm  breaks  forth  with  its  full  fury  and  attains  its 
height  at  the  moment  of  delivery.  After  delivery  a  marked  amelioration 
usually  occurs;  there  is,  at  the  same  time,  to  use  Peter's  words,  "a 
maternal  and  cardiac  delivery."  But  at  each  new  pregnancy  there  is  an 
exacerbation,  and  the  j)atients  succumb  to  the  cardiac  cachexia.  Death 
usually  occurs  during  the  puerperal  state,  Porak  noted  the  following 
conditions  in  eighty-four  cases  of  pregnant  women  suffering  from  cardiac 
troubles:  The  condition  remained  stationary  in  twenty-one,  was  aggravated 
during  pregnancy  in  fifty-five,  and  during  labor  in  eleven.  Ameliora- 
tion after  delivery  was  noted  in  twenty-two  cases,  thirty-one  women 
died,  five  before  delivery,  two  during  delivery,  and  twenty-five  during 
the  puerperium.  We  may  say,  then,  without  hesitation,  that  pregnancy 
hastens  the  course  of  cardiac  diseases,  and  predisposes  particularly  to 
pulmonary  congestion  and  embolism. 

The  Influence  of  Cardiac  Diseases  on  Pregnancy. — Diseases  of  the 
heart  show  their  influence  on  joregnancy,  by  causing  metrorrhagia, 
premature  delivery,  and  abortion,  and  by  causing  the  death  of  the 
foetus,  either  directly  on  account  of  the  mother's  affection,  or  in  con- 
sequence of  changes  in  the  jolacenta. 

I.  Metrorrhagia. — Attacks  of  metrorrhagia  may  be  produced  at  the 
usual  time  of  the  menstrual  flow,  and  may  thus  give  rise  to  the  belief 
that  menstruation  persists  during  jDregnancy,  but  they  differ  from  it 
as  regards  both  the  amount  and  the  quality  of  the  blood,  and  the 
duration  of  the  flow.  Duroziez  has  reported  several  cases.  Metrorrhagia 
may  occur  before  the  expulsion  of  the  foetus,  but  it  is  especially  observed 
at  the  time  of  delivery;  it  accompanies  premature  delivery  and  abortion, 
and  is  usually  referable  to  uterine  inertia.  The  hemorrhage  may  be  so 
excessive  as  to  threaten  the  life  of  the  woman. 

II.  Abortion  and  Premature  Lahor. — These  are  very  frequent,  and 
the  children  who  are  born  at  full  term  do  not  live  long.  According  to 
Casanova,  they  do  not  occur  except  in  the  case  of  women  in  whom  the 
valvular  lesion  has  already  been  manifested  by  symjotoms  more  or  less 
marked,  as  dyspnoea  and  pali^itations.  They  reappear  with  so  much  the 
more  readiness,  according  as  there  have  been  previous  pregnancies.  He 
believes  that,  in  more  than  half  of  the  cases,  the  pregnancy  is  not  com- 


DISEASES    OF   PREGNANCY.  49 

pleted,  and  that  the  cliild  may  be  born  in  three  conditions — dead,  living, 
or  expelled  prematurely.  According  to  See,  the  foetus  perishes  from 
asphyxia  and  inanition,  because  it  no  longer  finds  in  the  vitiated  blood 
of  the  mother  either  the  oxygen  or  the  other  materials  necessary  for  its 
nutrition.  It  then  becomes  a  foreign  body,  which  is  soon  expelled  from 
the  uterine  cavity. 

llie  Fmtus  is  lorn  Dead. — The  most  rational  explanation  of  this  is 
that  of  Brown-Sequard  and  Marty,  which  is  as  follows.  Venous  blood 
stimulates  the  nerve-centres  and  contractile  tissues;  oxygen  furnishes  the 
contractile  force,  carbonic  acid  sets  it  in  motion.  In  this  way  is  produced 
the  contraction  of  the  uterus,  which  is  so  useful  throughout  the  entire 
course  of  pregnancy,  in  preventing  stagnation  of  the  blood  in  the  uterine 
sintises  and  plexuses.  But,  as  soon  as  some  cause  disturbs  the  general  cir- 
culation, and  increases  the  embarrassment  of  the  uterine  circulation  (car- 
diac or  pulmonary  disease),  the  uterine  contractions  become  so  strong  as 
to  exceed  the  physiological  limit,  producing  either  abortion,  or  premature 
delivery.  Abortion  results  from  congestion  and  hemorrhage  into  the 
placental  tissue,  separating  the  placenta,  and  extending  within  the  uterus 
as  in  other  organs.  Duroziez  noted  21  miscarriages  among  41  women 
with  heart  disease,  5  were  delivered  at  six  months,  and  37  of  the  children 
who  were  born  alive,  died  before  reaching  five  years.  Among  220  cases 
collected  by  Oourrejol  and  Porak,  128  were  delivered  at  terms. 

Prognosis.— Although  the  prognosis  is  evidently  grave,  both  for  the 
mother  and  for  the  child,  generally  speaking  it  varies  according  to  the 
different  lesions.  All  writers  agree  in  regarding  mitral  lesions  as  far 
more  serious  than  aortic;  the  latter,  says  Casanova,  and  especially  steno- 
sis, are  not  dangerous  affections,  but,  on  the  contrary,  they  are  well 
borne,  and  are  compatible  with  long  life,  and  if  it  were  not  for  the  con- 
tinual fear  of  fatal  syncope,  or  of  premature  weakening  of  the  heart's 
contractions,  the  prognosis  would  be  quite  favorable.  Others  believe 
that  the  lesions  become  aggravated  during  the  latter  months  of  preg- 
nancy, and  undergo  amelioration  afterward.  It  is  believed  that  aortic 
stenosis  in  particular,  may  exert  a  very  injurious  influence  on  pregnancy. 
Aortic  insufficiency  is  characterized  by  its  long  period  of  immunity, 
which  depends  upon  the  compensatory  hypertrophy  of  the  left  ventricle. 
See  thinks  that  the  lesion  is  perfectly  compatible  with  gestation,  at  least 
that  there  are  no  functional  symptoms.  This  is  not  always  the  case,  and 
sudden  death  may  occur.  Mitral  lesions  are  unquestionably  the  most 
serious  of  all,  although  opinions  differ  with  regard  to  stenosis.  "When 
the  latter  is  combined  with  insufficiency  the  prognosis  is  much  worse. 
Mitral  lesions  lead  to  dyspnoea,  congestions,  and  pulmonary  troubles. 
Lesions  involving  simultaneously  different  valves  are  the  most  grave; 
those  of  the  right  heart  are  secondary  according  to  Berthiot,  but  Lee 
Vol.  n. — 4. 


50  A   TREATISE    ON    OBSTETRICS. 

cites  a  case  in  which  a  pregnant  female  with  a  pre-existing  tri-cuspid 
lesion  died  during  an  attack  of  pulmonary  congestion. 

Porak  has  constructed  a  table,  based  on  92  cases  of  heart-disease,  35 
of  which  terminated  fatally.  The  mitral  valve  was  aifected  in  54,  the 
aortic  in  13,  and  botli  valves  in  32;  the  foetus  was  expelled  prematurely 
in  all  but  3  cases.  He  regards  mitral  stenosis  as  a  very  serious  affection, 
often  terminating  fatally. 

Treatment. — In  view  of  the  fatal  influence  mutually  exerted  by  preg- 
nancy and  diseases  of  the  heart,  the  first  question  which  presents  itself 
is,  "Ought  we  to  allow  a  young  woman  with  heart-disease  to  marry?" 
In  general  we  reply  in  the  negative,  especially  if  a  mitral  lesion  is  pres- 
ent; strictly  speaking,  perhaps,  we  may  be  less  positive  if  the  lesion  is 
aortic,  but,  even  then  it  is  well  to  warn  the  family  of  the  danger  to  which 
they  would  expose  the  girl,  and  Peter's  opinion  ought  to  be  regarded  as 
a  rule  which  is  almost  absolute,  viz.:  Oppose  marriage  in  a  patient  with 
heart-disease;  if  she  is  married,  do  not  let  her  become  a  mother;  if  she 
is  a  mother,  prevent  her  from  nursing  her  child;  and  if  such  a  patient 
become  pregnaut,  let  her  avoid  most  carefully  fatigue,  emotion,  and 
every  cause  which,  by  disturbing  the  pulmonary  circulation,  may  render 
still  graver  the  prognosis  of  the  cardiac  affection. 

Medical  Treatment. — This  can  not  be  laid  down  arbitrarily.  Peter 
recommends  venesection  highly;  this  is  undoubtedly  useful  in  reliev- 
ing congestion  of  cardiac  origin.  Digitalis  certainly  acts  favorably  in 
many  cardiac  affections,  but  it  is  not  adapted  to  all.  It  is  certain  that  it 
relieves  palpitations  and  produces  diuresis,  but  it  does  not  affect  palpita- 
tion of  purely  nervous  origin,  in  which  bromide  of  potassium  combined 
with  ether  is  of  utility,  and,  where  pain  is  present,  local  bleeding  is 
attended  with  good  results.  Peter  uses  digitaline,  but  we  prefer  the 
tincture  of  digitalis,  or  the  infusion  of  the  leaves,  in  doses  of  three  grains. 
The  troubles  arising  from  hsematosis  should  be  treated  with  venesection, 
sulphuret  of  mercury  in  doses  of  two  and  a  half  grains,  ipecac,  inhalations 
of  volatile  salts,  compressed  air,  preparations  of  iron,  calomel  with 
squills  and  digitalis,  turpentine,  purgatives,  diuretics,  etc.  Can  we  use 
chloroform  during  labor  in  the  case  of  a  pregnant  woman  with  heart 
disease?  This  question  has  never  been  definitely  settled.  We  know 
that  nearly  all  surgeons  regard  affections  of  the  heart  as  contra-indicat- 
ing the  use  of  this  ansesthetic.  Championniere  administers  chloroform 
to  all  of  his  operative  cases  without  distinction. 

Obstetrical  Treatment. — If  the  woman  does  not  present  any  serious 
troubles,  the  only  thing  to  do  is  evidently  to  wait;  but,  if  they  become 
more  serious,  and  the  life  of  the  woman  seems  to  be  in  jeopardy,  should 
we  confine  ourselves  to  purely  expectant  treatment,  and  merely  combat 
the  cardiac  symptoms?     Two  cases  may  present  themselves. 


DISEASES    OF    PREGNANCY.  51 

I.  Laljor  Ms  Commenced. — In  this  case,  all  accoucheurs  agree  with 
Pajot  and  Dubois  whose  ideas  are  quoted  iu  Dubois's  article.  The  or- 
dinary and  evident  indication  is  to  terminate  the  labor  as  rapidly  as  ^ob- 
sible  without  injury  to  the  mother,  without  injury,  because  we  absolutely 
disapprove  of  forced  delivery.  The  five  cases  mentioned  by  Porak  in  his 
article,  do  not  appear  to  us  to  warrant  a  like  management,  and  the  bad 
results  given  by  the  general  adoption  of  forced  delivery  do  not  appear 
much  improved,  according  to  the  observations  to  which  we  refer — i.e., 
one  child  really  survived;  for  in  the  four  other  cases,  twice  the  infant 
died,  and  twice  its  fate  was  not  known.  As  for  the  motliers,  the  results 
seem  a  little  more  favorable,  but  still  the  observations  are  too  incomplete 
to  allow  us  to  judge  of  the  question. 

II.  Labor  has  not  Commenced. — Ought  labor  to  be  induced,  when  we 
know  the  danger  which  threatens  the  life  of  the  mother,  and  consequently 
that  of  the  child  ?  All  authors  agree  on  this  subject,  and  all  answer  in  the 
affirmative.  We  are  iu  accord  with  this  opinion.  But  ought  abortion  to 
be  produced  ?  In  this  case  the  child's  life  is  sacrificed  to  prolong  the  life 
of  the  mother,  a  life  very  much  endangered  not  only  at  present  by  actual 
dangers,  but  in  the  more  or  less  remote  future  by  some  cardiac  disease 
even.  Besides,  authorities  are  not  agreed;  some  disapprove  entirely  of 
the  production  of  abortion,  others  believe  in  producing  an  abortion,  but 
under  certain  conditions. 

"We  place  ourselves  among  the  latter.  We  do  not  forget,  however,  that 
producing  abortion  is  a  serious  operation  when  viewed  from  a  moral 
standpoint,  and  we  only  believe  ourselves  authorized  to  do  so  when  all 
other  therapeutic  measures  have  been  exhausted,  and  when  the  life  of 
the  mother  is  in  serious  and  imminent  peril  by  intense  and  persistent 
gravido-cardiac  complications. 

Finally,  if  the  mother  dies,  and  the  <3hild  is  viable,  it  is  the  duty  of 
the  accoucheui  to  j)erform  the  Cesarean  section  without  hesitation. 
Whatever  be  the  chance  for  the  child,  no  one  has  the  right  to  deprive 
it  of  that  one  chance.  We  will  return  again  to  this  subject  in  the 
chapter  devoted  to  delivery  post  mortem. 

Varices. 

Three  situations  are  particularly  the  seat  of  varices  in  pregnant  women. 
These  places  of  election,  so  to  speak,  are  the  lower  extremities,  the 
genital  organs,  external  and  internal,  the  anus  and  the  rectum.  But 
these  places  are  not  the  only  ones  invaded,  they  have  been  met  with  on 
the  trunk,  and  finally  they  may  extend  into  the  bladder  and  urethra, 
thus:  1.  Varices  of  the  lower  extremities;  2.   Varices  of  the  internal  and 


52  A    TREATISE    ON    OBSTETRICS. 

external  genital  organs;  3.  Varices  of  the  anus  and  rectum.  4.  Varices 
of  the  trunk;  5.  Varices  of  the  urethra  and  bladder. 

I.  Varices  of  the  lower  extremities  may  be  superficial  or  deep. 

(a.)  Superficial    Varices. — Briquet  distinguishes  four  varieties: 

1st.  8wij)le  Enlargement. — The  vessels  have  a  greater  calibre  than 
usual,  but  they  remain  contractile  and  are  not  tortuous,  their  walls  do 
not  become  thin,  but  always  have  a  thickness  proportionate  to  the  calibre 
of  the  vessel. 

2d.  TJniform  Dilatation  ivith  Tliickening. — According  to  Verneuil,  the 
calibre  of  the  vessel  is  increased,  its  form  remains  cj'lindrical,  but  the 
underlying  connective  tissue  alone  being  hypertrophied.  there  is  not 
only  thickening  and  lengthening,  but  tortuosity,  and,  on  section,  the 
vessels  remain  gaping,  and  their  internal  surface  show  some  longitudinal 
folds  and  ridges. 

3d.  Unequal  Dilatation  with  Thickening  and  Thinning. — The  changes 
here  are  greater  and  involve  all  the  coats.  There  is  at  the  same  time  a 
multiplication  and  elongation  of  the  flexures,  but  the  middle  coat  is  no 
longer  regularly  hypertrophied,  but  it  is  thick  in  certain  places  and 
thin  in  others;  hence  the  swellings,  the  unequal  dilatation  forming  true 
vai'icose  swellings  of  various  shapes  and  appearances.  The  valves  in 
the  veins  being  very  much  altered,  the  venous  circulation  is  seriously  modi- 
fied. 

4th.  Venosity. — This  is,  according  to  Briquet,  simply  development 
of  small  veins  which  are  very  numerous,  enlarged  and  branching  indefi- 
nitely. They  are  very  superficial,  even  sub-epidermic,  and  they  may 
color  the  skin  violet  or  bright  red. 

According  to  Cornil,  "the  varicose  dilatations  of  less  degree,  and 
these  are  the  most  common,  are  produced  by  a  new  formation  of  connec- 
tive tissues  (bundles  of  fibres  and  cells),  by  the  extension  of  the  vasa- 
vasorum,  which  penetrate  as  far  as  the  internal  part  of  the  middle  layer, 
by  the  distension  or  sinuous  state,  the  winding  condition  and  the  thick- 
ening, more  or  less  considerable,  of  the  walls  of  those  vessels,  and  by 
extravasation  of  the  coloring  matter  of  the  blood  in  the  connective 
tissue  of  the  walls  of  the  veins. 

The  thickness  of  the  middle  layer,  thus  modified,  is  from  two  to  ten 
times  greater  than  in  the  normal  state.  In  these  sack-like  or  fusiform 
dilatations  of  the  varicose  veins,  the  wall  is  very  thin,  the  internal 
surface  is  smooth,  the  dilatation  is  very  irregular,  and  the  periphery  of 
the  tumor  is  easily  separated  from  the  surrounding  tissue.  The  dilata- 
tion on  section  shows  that  the  middle  fold  has  almost  or  entirely 
disappeared.  The  membrane  which  constitutes  the  dilated  pouch  is 
composed  almost  wholly  of  the  connective  tissue,  modified  by  external 
tissues  and  by  the  internal  tunic  of  the  vein. 


DISEASES    OF    PREGIN^ANCY.  53 

Varices,  in  a  word,  are  the  result  of  a  chronic  inflammation  of  the 
veins,  characterized  essentially  by  the  multiplication  of  the  elements  of 
the  connective  tissues  (bundles  and  cells),  above  all  of  tlie  internal  layer 
of  the  middle  membrane,  by  the  distension  and  extension  of  the  net- work 
of  the  vasa-vasorum,  and,  secondarily,  by  the  dilatation  and  by  the 
calcareous  degeneration  of  the  walls  of  the  changed  vessels.  The  blood 
remains  in  the  normal  condition,  and  the  veins  seem  covered  in  the 
midst  of  indurated  tissue.  Budin  believes  that  this  is  due,  not  to  a  true 
induration,  but  to  a  simple  infiltration  of  the  surrounding  tissues.  He  has 
eaid,  with  reason,  that  this  induration,  this  thick  lining,  disappears 
almost  immediately  after  confinement. 

(b.)  Deep  Varices. — Verneuil  acknowledges  that  the  primary  situation 
of  varices  lies  in  the  deep  veins,  and  above  all,  in  the  muscular  and 
intramuscular  veins  of  the  calf.  These  deep  vessels  are  at  first  the  seat 
of  dilatation,  and  of  valvular  insufficiency,  and  thus  two  modifications 
are  transmitted  to  the  other  branches  of  the  sub-aponeurotic  tissue. 

Superficial  varices  would  be  then  only  the  consequence,  only  the 
manifestation  of  the  deep  varices. 

Si/mptoms. — They  differ  according  as  we  have  to  do  with  superficial 
or  deep  varices.  They  have  a  difEerent  appearance  according  to  their 
situation  and  the  degree  of  dilatation.  Sometimes  they  are  capillary 
varices,  located  on  the  feet,  ankles  or  calves  of  the  legs;  sometimes  they 
form  blue  or  red  spots  analogous  to  nsevi,  scattered  over  different  areas, 
running  up  on  the  thigh  and  connecting  among  themselves  by  long 
vesicles.  In  a  condition  more  advanced,  the  dilated  veins  are  longer; 
they  form  sometimes  lozenge-shaped  meshes,  at  other  times  isolated 
tortuosities,  or  finally  there  may  be  true  bundles  of  dilated  veins. 

Ordinaril}'',  che  neighboring  tissue  is  thickened,  infiltrated,  as  in 
oedema;  at  other  times,  on  the  contrary,  these  veins  seem  separated 
from  the  finger  by  an  extremely  thin  septum.  When,  on  the  other 
hand,  there  is  a  coagulum  formed,  the  veins  then  take  the  form  of  a 
hard  cord,  knotty,  and  roll  more  or  less  under  the  finger. 

Varices  are  most  common  in  the  external  saphenous;  they  may  extend 
down  the  leg  on  the  posterior  and  inner  surface  of  the  calf.  On  the 
inner  surface  these  varicose  tumors  may  be  of  variable  size,  sometimes 
enormous,  accompanied  with  oedema,  weight,  itching,  dullness  and  even 
a  sort  of  paralysis  of  the  extremities.  The  first  appearance  may  be  in 
the  first  pregnancy,  may  be  after  several  pregnancies.  They  may  man- 
ifest themselves,  during  the  first  months  or  more  slowly,  and  go  on 
increasing  with  the  pregnancy. 

At  other  times  they  show  themselves  in  one  pregnancy  and  not  in 
another.  Finally,  they  may  disappear,  if  not  completely,  at  least  in 
great   part,  after   confinement.     Labor,  according  to   Budin,  does   not 


54  A   TREATISE    O'N    OBSTETRICS. 

modify  them,  it  would  have  indeed  the  contrary  effect.  According  to 
Cazin,  the  varices  would  be  swollen  and  tumefied. 

Verneuil  has  given  a  masterly  description  of  the  symptoms  in  cases  of 
deep  varices.  "There  is  at  first  a  feeling  of  fatigue  in  walking,  an 
extreme  heaviness  of  the  affected  extremity,  accompanied  by  an  appreci- 
able numbness;  next,  frequent  cramps  of  the  calves,  accompanied  by 
prickling  or  itching.  When  the  numbness  and  pain  acquire  a  certain 
intensity,  the  limbs  become  weak  and  trembling  and  can  scarcely 
support  the  weight  of  the  body.  The  pain  is  limited,  in  general,  to  the 
back  part  of  the  leg,  reaching  its  maximum  in  the  calf.  It  is  deeply 
seated,  poorly  circumscribed,  and  manifests  itself  often  in  the  sole  of 
the  foot,  and  ceases  at  night,  and,  in  the  recumbent  position,  may 
come  on  gradually,  or  is  of  sudden  onset. 

"It  appears  again  in  resuming  the  vertical  position  or  in  walking. 
The  involvement  of  the  superficial  varices  does  not,  necessarily,  increase 
the  difficulty,  and  the  extremities  which  offer  only  venosities  are  often 
the  most  painful.  This  pain  may  be  referred,  according  to  Verneuil,  to 
the  nearness  of  the  dilated  veins  to  the  accompanying  nerves.  The 
limb,  to  the  touch,  appears  doughy;  when  it  is  quiet  and  reduced  in 
size  it  gives  a  spongy  sensation,  analogous,  in  some  cases,  to  that  of 
varicocele. 

"In  places  one  caa  make  out  indurations,  nodosities,  situated  in  the 
midst  of  soft  tissue.  These  are  due  to  phleboliths,  to  clots  of  blood, 
signs  of  circumscribed  phlebitis,  or  of  spontaneous  coagulation.  Often 
the  varicose  extremities  are  studded  with  brown  patches,  as  pigment, 
various  eruptions  scattered  over  the  surface  of  the  skin  (small  boils, 
erythema,  eczema,  prurigo),  and  accompanied  by  itching,  which'  often 
precedes  the  appearance  of  subcutaneous  varices.  The  perspiration 
is  increased  in  tlie  affected  limb;  perhaps  there  is  an  increase  even  in 
the  local  temperature." 

Authors  are  not  agreed  as  to  the  frequency  of  varices,  because,  while 
Cazin  has  only  met  78  cases  in  1659  confinements,  Lesguillon  has 
reported  1  case  in  20,  and  Budin  has  met  them  100  times  in  300  cases. 

Etiology. — The  following  have  been  successively  assigned  as  a  cause: 
Weight,  the  number  of  pregnancies,  occupation,  the  position  of  the 
uterus,  temperature,  pendulous  abdomen,  deformities  of  the  pelvis, 
cardiac  disease,  pulmonary  disease,  and  age  of  the  woman.  All  these 
causes  may  operate  in  certain  cases,  but  they  are  found  as  well  in  women 
who  have  no  varicose  veins. 

Pressure  of  the  uterus  on  the  vascular  trunks  has  also  been  assigned 
as  a  cause,  but  the  development  of  varices  is  far  from  being  in  harmony 
with  the  development  ai^d  inclination  of  the  uterus. 

Richard  has  proposed  the  following  theory:  "In  consequence  of  the 


DISEASES    OF    PREGN"A]S^CY.  55 

development  of  the  organs  of  gestation,  the  arteries  increase  in  size,  the 
veins  develop  equall}^,  and  seem  to  communicate  more  easily  with  tlie 
arteries.  As  a  result,  the  veins  of  tlie  pampilii'orm  plexus  dilate  nnder 
the  influence  of  intravenous  jjressure;  consequently,  the  hlood  passes 
more  rapidly  and  easily  toward  the  dilated  capillaries,  and  the  longer 
the  dihiting  force  lasts,  the  longer  will  it  tend  to  dilate  the  vessels. 

"The  increase  of  venous  pressure  in  the  veins  forming  the  plexus 
which  runs  along  the  side  of  the  uterus,  will  have  for  its  effect  increased 
tension  in  all  the  great  vessels,  which  serve  as  an  outlet  to  the  veins  of 
the  uterine  system,  that  is  to  say:  1st.  Into  the  left  renal  vein;  2d. 
Into  the  inferior  vena  cava;  3d.  Into  the  hypogastric  vein,  and,  by  the 
intermediate  veins,  into  the  common  iliac  vein.  The  blood  of  the  venous 
system,  situated  below  the  vena  cava  inferior,  finding  before  it  a  tension 
superior  to  its  own,  slackens  its  flow;  thence,  stasis  in  the  hypogastric, 
femoral,  popliteal,  posterior  tibial,  the  saphenous  and  their  tributaries, 
and  consequent]}''  the  formation  of  varices." 

Budin  rightly  observes  that  with  this  theory  it  is  difficult  to  explain 
the  cases  in  which  varices  appear  in  the  first  months  of  pregnancy. 

The  increase  in  the  mass  of  the  blood,  modifications  in  its  composition, 
increase  of  vascular  tension  (LesguilloD),  changes  in  the  nervous  system 
(Dubois,  Barnes),  weakening  of  the  venous  walls  by  the  simple  fact  of 
pregnancy,  are  assigned  as  causes.  All  these  causes  may  act,  but  it  is 
difiicult  to  say,  as  Budin  avers,  to  which,  in  each  particular  case,  any 
belong. 

Varices  in  pregnant  women  may  be  complicated  with  oedema,  but  not 
so  frequently  as  one  might  suppose.  Lesguillon  has  only  quoted  one  case 
in  47v  women,  and  moreover  oedema  can  exist  without  varices,  varicose 
ulcers  rarely  (because  Lesguillon  gives  2  cases  in  47  women);  erysipelas 
and  phlebetis,  these  are  common.  Everything  then  goes  on  as  in 
limited  phlegmon;  but  in  some  exceptional  cases,  this  phlebitis  may  be- 
come ihe  cause  of  purulent  infection  of  emboli  (Budin,  Blot).  Lastly, 
varices  may  break,  and  these  ruptures  may  be  followed  by  serious  and 
even  fatal  hemorrhages. 

It  is,  in  general,  above  the  malleoli  that  they  take  place,  and  they 
may  be  spontaneous  or  they  may  be  produced  under  the  influence  of  a 
blow  or  shock.  When  they  are  arrested,  they  do  not  generally  endanger 
the  pregnancy. 

Complications  alone  make  the  prognosis  serious.  In  the  treatment  of 
simple  varices  one  is  limited  to  rest,  and  the  employment  of  an  elastic 
stocking,  which  has  some  advantages;  if  complications  arise,  these  ought 
to  be  the  guide  for  treatment.  Euge,  Martin,  Otto  Albert,  Spiegelberg, 
have  advised  a  radical  cure  of  varices  during  pregnancy,  i.e.,  in  making 
subcutaneous  injections  repeated  in  different  places,  of  fid.  ex.  ergot  in 


56  A   TREATISE    ON    OBSTETRICS. 

doses  of  two  grains.  Since,  Budin  justly  observes,  tlie  varices  should 
disappear  ordinarily  or  be  improved  considerably  at  tlie  end  of  tlie  con- 
finement, it  is  best  then  to  try  palliative  methods,  and  contend  against 
the  complications  with  suitable  treatment. 

II.  Varices  of  tlie  genital  Organs. — They  may  be  formed  on  the  vulva 
or  even  as  far  as  the  cervix;  lastly,  they  may  extend  into  the  broad  and 
round  ligaments.  Situated  ordinarily  between  the  labia  majora  and 
minora,  often  on  the  labia  majora  alone,  they  may  be  unilateral,  extend 
as  far  as  the  clitoris  to  the  mons  veneris,  invading  more  or  less  the  vagina; 
form  varicose  tumors  more  or  less  long  on  the  labia  majora,  the  walls  of  the 
vagina  (occasionally  only  on  these  walls),  and  extend,  as  Budin  has  shown, 
as  far  as  the  cervix,  broad  ligament,  and  even  to  the  round  ligament. 
Distorting  more  or  less  these  parts,  giving  them  a  bluish,  livid  or  tume- 
fied aspect,  they  may  break  and  produce  hemorrhages  more  or  less  severe. 
The  ruptures  may  be  produced  either  during  pregnancy  or  during 
confinement.  During  pregnancy,  the  rupture  may  be  spontaneous  or 
be  the  result  of  scratches,  falls,  shocks  and  blows  on  the  vulva.  During 
confinement,  it  is  at  the  time  of  the  birth  of  the  child  or  soon  after  that 
the  rupture  takes  place,  and,  if  these  varices  are  within  the  vagina,  they 
may  become  the  origin  of  thrombi,  which  we  will  study  further  on  more 
in  detail. 

III.  Varices  of  the  Amis  and  loiver  part  of  the  Rectiim. — They  give 
rise  to  hemorrhages,  which  are  found  so  often  during  pregnancy,  and, 
oddly  enough,  often  after  confinement. 

It  is  the  constipation  so  habitual  in  pregnant  women,  and  the  strain- 
ing which  they  make  in  the  act  of  defecation,  which  is  in  reality  the 
true  cause  of  these  hemorrhoids.  ISTot  serious,  in  general,  during 
pregnancy,  they  may  be  after  confinement,  filling  up  the  anus,  where 
they  form,  sometimes,  an  enormous  pad,  extremely  painful.  The^^  may 
become  the  seat  and  focus  of  anal  fistulse  (we  have  seen  two  cases),  and 
during  pregnancy  of  serious  hemorrhage  (we  have  seen  an  example  of 
this). 

IV.  Varices  on  the  TrunJc. — In  this  case  it  is  chiefiy  on  the  abdomen 
where  they  are  found  in  greatest  number.  To  the  case  reported  by  Petit 
and  Budin,  we  can  add  one  which  occurred  in  our  practice.  The  varices 
reached  as  high  as  ihe  chest  and  even  on  one  breast.  Eichard  has 
reported  one  similar  case  (varices  of  the  mammae).  Cazin  finally  has 
seen  a  case  of  varices  on  the  buttocks. 

V.  Varices  of  the  Urethra  and  Bladder. ■ — Budin  has  reported  some 
cases  from  Skene,  Eichet,  Winckel  and  Bar. 

Serous  Diathesis — Ascites — Dropsies. 

Among  the  morbid  phenomena  which  arc  the  result  of  disturbances  of 
the  circulating  system,  must  be  mentioned  first  the  dropsies  of  pregnant 


DISEASES    OF    PREGNANCY.  57 

women,  which  have  their  seat  in  the  cellular  tissue,  and  may  extend 
even  to  the  great  serous  cavities.  Stolz  and  his  pupils  Thierry,  Lauth, 
Schindler,  wished  to  make  one  morbid  entity,  and  have  classed  all  these 
phenomena  under  the  name  of  serous  diathesis,  serious  cachexia  of  preg- 
nant women,  and  of  the  recently  confined  woman. 

We  believe,  for  our  part,  that  they  have  gone  too  far  in  this  matter, 
and  that  the  dropsies  which  occur  in  pregnant  women,  and  those  lately 
confined,  are  only  the  manifestation  of  a  general  state,  in  which,  it  is 
true,  the  altered  state  of  the  blood  is  the  chief  cause,  but  which,  apart 
from  this  altered  blood  state,  may  be  produced  by  a  group  of  causes  in- 
dejsendent  of  each  other.  In  our  opinion  there  is  a  great  difference 
between  dropsies  which  may  occur  during  pregnancy,  and  those  which 
manifest  themselves  after  confinement,  and  we  admit,  completely,  the 
division  which  Eaymond  has  given  of  the  puerperal  state;  minor  and 
major  j)uerperal  state.  For  us,  it  is  impossible  to  compare  precisely  the 
condition  of  a  woman  during  pregnancy  and  that  of  a  woman  after 
confinement.  During  pregnancy,  as  Pajot  has  said,  all  tends  to  hyper- 
trophy, afterward  all  to  atrophy.  And  although  the  puerperal  period, 
in  our  opinion,  commences  with  conception,  only  to  finish  after  confine- 
ment, according  to  all  authorities  the  true  puerperal  state  commences 
only  after  the  confinement,  or  better  still  after  the  labor,  and  it  impresses 
with  a  peculiar  gravity  all  the  affections,  which,  happily,  rarely  affect 
women  during  pregnancy.  Besides,  this  is  what  is  shown  by  the  study 
of  the  works  of  Lauth,  Thierry,  and  Thirion  de  ISTamur;  because  their 
observations  referred  almost  always  to  those  women  recently  confined. 
There  may  be  a  relation  between  dropsies  which  occur  during  pregnancy 
and  those  which  occur  after  labor;  this  fact  is  unquestionable,  but  in 
this  last  case  the  puerperal  period  plays  the  chief  part. 

Assuredly  we  do  not  question  the  considerable  influence  in  the 
production  of  these  dropsies  played  by  the  altered  state  of  the  blood  in 
pregnant  women,  so  well  studied  to-day,  both  in  quality  and  quantity; 
but  the  diminution  of  the  albumin  does  not  suffice  to  explain  all  the 
dropsies  of  pregnant  women,  and  of  those  recently  confined,  and  we  do 
not  believe  that  the  cachexia,  the  serous  diathesis  of  pregnant  women  or 
of  those  recently  confined,  can  be  considered  as  a  true  morbid  entity. 
If  it  were  so,  all  pregnant  women  would,  in  different  degrees,  present 
these  dropsies,  and  they  constitute,  on  the  contrary,  the  exception, 
chiefly  in  their  serious  forms. 

We  cannot  accept  then,  as  absolutely  true,  the  definition  of  Schindler: 
"The  serous  cachexia  of  pregnant  and  recently  confined  women,  is  pro- 
duced by  a  general  or  partial  dropsy  of  the  cellular  subcutaneous  tissue, 
by  extravasation  into  the  serous  cavities,  or  by  the  infiltration  of  the 
interstitial  tissue  of  vital  organs,  all  united  to  diminish  the  albumin  of 
the  blood  during  pregnancy." 


58  A    TEEATISE    ON   OBSTETRICS. 

The  pupils  of  Stoltz  themselves  are  not  all  agreed,  because,  while 
Thierry  admits  a  serous  diathesis,  Lauth  and  Schindler  admit  serous 
cachexia.     We  refer  to  the  thesis  of  Lauth  for  the  history  of  the  subject. 

Scanzoni,  who  designated  this  condition  under  the  name  of  serous 
cachexia,  affirmed  that  "this  state  of  the  blood,  common  in  pregnant 
women,  gave  rise  to  a  serous  exudation,  often  abundant  in  the  serous 
cavities  (pericardium,  pleura,  peritoneum),  in  the  cellular  tissue  under 
the  skin  and  sub-serous  tissue  (lower  extremities,  vulva  and  vagina), 
in  the  parenchyma  of  some  organs  (lung  and  brain,  even  to  a  transuda- 
tion into  the  cavity  of  the  amnion  (liydramnion),  and  into  the  internal 
walls  of  the  uterus  (hydrorrhcea).  This  condition  endangers  the  life 
of  the  mother  and  child.  Its  influence  during  pregnancy  deserves  the 
more  attention,  because  to  it  is  added  the  pressure  exercised  by  the 
distended  uterus  on  the  neighboring  organs. 

"Thus,  pulmonary  oedema,  effusion  into  the  2>leura  and  into  the 
pericardium,  become  more  sei'ious,  because  of  the  obstacle  which  the 
uterus  presents  to  the  dilatation  of  the  thorax.  Thus  the  oedema  of  the 
lower  extremities  and  the  genitals  is  increased  by  the  pressure  on  the 
pelvic  vessels,  often  to  such  an  extent  that  motion  becomes  impossible, 
and  the  distension  of  the  skin  is  extremely  painful." 

Devilliers  and  Kcgnauld,  who  have  especially  studied  drojDsies  of  the 
cellular  tissue,  have  divided  them  into  two  great  classes.  ]st.  CEdema 
or  anasarca,  which  may  be  simple  or  involve  the  organs  of  respiration  and 
circulation.     2d.  Oedema  or  anasarca  with  albuminuria. 


Simple  (Edema. 

Causes. — The  first  chief  cause  consists  in  the  changes  of  the  blood, 
particularly  if  there  is  a  local  or  geueral  congestion,  a  febrile  state,  severe 
or  slight.  Age  and  child-bearing  have  no  influence,  but  it  is  not  the 
same  Avith  privation,  fatigue,  moral  influences,  living  in  unhealthy 
dwellings,  dampness — in  a  word,  all  the  causes  which  exert  a  depressing 
influence  on  the  pregnant  woman.  Sometimes,  however,  one  sees 
oedema  in  a  woman  in  a  robust  condition. 

But  to  these  general  causes  are  added  influences  which  we  call  local 
and  mechanical.  Among  them,  the  activity  of  a  new  life  which 
stimulates  the  uterus,  the  determination  of  a  considerable  amount  of 
blood  which  this  new  state  exacts,  are  the  powerful  causes  of  the  dis- 
turbance of  the  circulation.  They  may  wonderfully  modify  the  lower 
portions  of  the  body  and  induce  congestion  or  stasis,  of  which  they  may 
become  the  seat. 

It  is  through  the  development  of  the  uterus,  whose  influence  is  felt 


DISEASES    OF    PREGNANCY.  59 

ill  the  last  month  of  pregnancy;  the  inclination  of  the  ntems,  which 
explains  sufficiently  the  preference  of  tlie  infiltration  to  the  limb  on 
the  corresponding  side;  the  form,  the  direction  of  the  foetal  part,  the 
form  of  the  pelvic  cavity  and  its  unusual  size,  which  allows  communica- 
tion more  or  less  direct  belween  the  uterus  and  the  blood  vessels:  the 
resistance  of  the  abdominal  wall;  the  development  and  height  of  the 
uterus,  which  impedes  the  expansion  of  the  thorax;  the  large  size  of 
tlie  foetus;  the  increased  distension  of  the  uterus  by  twin  pregnancy, 
hydramnion,  tumors  of  the  foetus,  tumors  of  the  uterus  or  pelvis, 
abdominal  tumors,  prolonged  standing  in  certain  occupations;  finally, 
predisposition  in  certain  individuals  to  varices.  Such  are  the  main 
causes  of  simple  oedema. 

Prodhomme,  together  with  Andral  and  Gavarret,  Becquerel  and 
Eodier,  Eegnauld  and  Devilliers,  considered  the  alteration  of  the  blood 
as  the  preclisj)Osing  cause  (diminution  of  albumin);  but  it  must  play, 
like  these  last,  a  great  role  in  the  influence  of  the  mechanical  obstacles  to 
the  circulation;  the  serous  infiltration  which  complicates  these  condi- 
tions is  only,  according  to  him,  the  result  of  a  local  plethora.  He  tells 
us  that  the  influence  of  the  uterus  on  the  neighboring  organs  is  shown 
again  by  this  fact,  established  by  Depaul,  that  when  the  Cgesarean 
operation  is  performed,  one  almost  always  finds  a  varying  quantity  of 
serum  in  the  peritoneal  cavity.  It  is  the  same  in  supra-pubic  oedema, 
which  he  has  shown  is  present  in  case  of  twin  pregnancy. 

•(Edema  combined  ivitlb  Diseases  of  central  Organs. — Aside  from 
simple  oedemas,  we  find,  oedemas  or  anasarcas  with  affections  of  the 
central  organs  of  the  circulation  and  of  respiration.  In  this  condition, 
the  organic  causes  of  the  disturbance  of  the  circulation,  and  the  con- 
sequent infiltration  of  serum,  increases  again  all  those  conditions  which 
the  puerperal  state  in  women  developes.  If  dropsy  does  not  exist  before 
the  pregnancy;  it  will  develop  almost  certainly  in  its  course,  and  if  it 
had  already  shown  itself  beforehand,  it  will  increase  considerably  more 
in  simple  oedema.  This  is  the  case,  particularly  where  the  serous 
cavities  are  invaded,  and  then  we  have  ascites,  pleurisy  with  effusion, 
percarditis;  at  times  even  the  dropsy  will  commence  in  these  cavities. 
It  is  understood,  moreover,  that  these  are  dropsies  Avhich  induce  serious 
complications  for  mother  and  child  (symptoms  of  asphyxia,  premature 
expulsion  of  the  foetus,  etc.). 

(Edema  complicated  hy  Albuminuria. — In  this  case,  oedema  is  only  an 
accompanying  symptom,  and  it  is  the  albuminuria  which  constitutes  the 
disease. 

Symptoms  and  Course. ^^It  is  in  general  during  the  last  three  months 
of  pregnancy  that  oedema  commences  to  show  itself;  however,  when  it 
is  dependent  on  a  general  cause,  it  may  commence  with  pregnancy,  or 


60  A   TEEATISE    ON    OBSTETKICS. 

during  tlie  third  or  fourth  month  (Cazeaux);  and  while  it  shows  itself 
most  often  during  pregnancy,  it  may  only  aj)pear  after  confinement. 
Its  course  may  be  acute  or  chronic,  slow,  and  acccording  to  Lauth, 
Thierry,  Schindler,  there  are  three  degrees. 

1st.  Slow  Chronic  Form,  First  Degree. — Nearly  always,  the  swelling 
begins  in  the  lower  extremities.  It  is  noticed,  toward  evening,  that 
there  is  oedema  about  the  malleoli,  which  disappears  after  rest  and  the 
horizontal  position,  to  reappear  when  the  woman  remains  up  for  a  certain 
length  of  time.  As  the  pregnancy  advances,  the  infiltration  extends, 
reaches  the  feet,  legs,  knees  and  thighs,  and  no  longer  disappears  com- 
pletely during  the  night.  The  skin  becomes  dull,  pale,  is  now  insen- 
sible to,  and  pits  on,  pressure.  This  increase  in  size  of  the  lower 
extremities  is  accompanied  by  loss  of  motion  more  or  less  marked. 
Sometimes  it  is  utterly  impossible  to  stand,  on  account  of  the  vague 
pains  and  weight,  and  finally,  the  oedema  rising  still  higher,  ends  by 
involving  the  genital  organs,  and  becomes  a  considerable  inconvenience. 

In  the  second  degree,  the  oedema  continues  its  ascent,  involves  in  its 
turn  the  abdominal  wall,  forms  above  the  pubes  a  tumor,  quite  a  large 
cushion,  then  reaches  the  upper  extremities,  the  face,  eye-lids,  involving 
thus  all  the  cellular  tissue  under  the  skin,  and  giving  to  the  woman  a 
peculiar  appearance.  But  while,  according  to  Lauth,  it  remains  still 
limited  or  nearly  so  in  the  cellular  tissue  under  the  skin,  according  to 
Schindler,  the  peritoneum  is  involved  generally  in  its  turn  by  an  effusion 
more  or  less  abundant.  The  oedema,  carried  to  this  extent,  threatens 
the  woman  with  serious  complications.  As  evinced  by  the  feeling  of 
extreme  tension,  of  general  heaviness,  they  experience  vague  pains  in 
all  the  limbs;  the  respiration  becomes  difficult,  anxious,  oppressed,  and 
symptoms  of  asphyxia  and  syncope  manifest  themselves,  and  next  appear 
disturbances  of  digestion  and  diarrhoea.  The  urine  is  diminished,  of 
a  deep  red  color,  sometimes  albuminous;  the  pulse  is  small,  feeble,  and 
soft.  There  is  a  cardiac  bruit  transmitted  into  the  carotids;  but  won- 
derful as  it  may  seem,  fever  is  the  exception.  It  is  not  rare  in  this  case, 
in  view  of  the  condition  of  the  woman,  to  see  the  pregnancy  interrupted, 
and  the  patient  confined  prematurely  and  spontaneously,  usually  at  the 
end  of  the  eighth  month.  Carried  to  this  extent,  the  oedema  may  dis- 
appear after  confinement  (Lasserre,  Lauth),  but,  in  certain  cases,  it  is 
not  so,  and  the  dropsy  continues  to  increase,  and  the  disease  passes  into 
the  third  stage,  that  is  to  say,  the  effusion  spreads  into  the  great  serous 
cavities  of  the  abdomen,  thorax,  aad  skull,  and  death  results  quickly. 
We  may  add  that  these  oedemas,  so  extensive,  are  most  commonly  compli- 
cated by  albuminuria,  and  that  eclampsia  comes  in  its  turn  to  add  its  deadly 
influence  to  the  troubles  experienced  by  the  woman,  already  so  severe. 

The  third  degree  is  accompanied  always,  contrary  to  the  first  two,  by 


DISEASES    OF    PRIiGNANCY.  61 

a  true  rise  of  temperature,  is  characterized  by  effusion  in  tlie  serous  cavi- 
ties; it  may  originate  only  after  confinements,  or  show  itself  already  dur- 
ing pregnancy,  and  one  may  understand  without  difficulty  the  danger 
which  it  brings  with  it,  both  for  the  mother  and  child.  Such  is  the 
common  course  of  a3dema,  in  pregnant  women,  but  it  is  not  always  so. 

Second  Form,  Acute. — In  some  cases  it  takes  a  course  truly  acute, 
and  is  then  generally  accompanied  by  some  fever. 

It  is,  moreover,  in  these  grave  cases  that  one  meets  with  infiltration  in 
the  upper  extremities  and  in  the  serous  cavities.  But  as  Prodhomme 
remarks,  '.'while  the  effusion  in  the  serous  cavities  generally  only  advances 
according  as  the  infiltration  rises  from  the  lower  to  the  upper  parts, 
the  visceral  oedema,  so  to  speak,  more  independent  of  the  state  of  general 
infiltration,  sometimes  waits  to  form  until  the  latter  has  attained  a  con- 
siderable degree,  sometimes  declares  itself  when  the  infiltration  of  the 
lower  extremities  is  scarcely  marked.  Then  they  may  appear  rapidly, 
presenting  in  their  progress  the  characters  of  the  metastatic  serous  con- 
gestion which  Lasserre  has  noted  in  the  recently  confined  woman.  It  is 
then  that  we  see  arise  pulmonary  osdema,  pleuritic  pericardial  effusions,  se- 
rous effusion  into  the  cranial  cavity,  cerebral  oedema,  and  finally 
death." 

Of  all  the  serous  cavities,  that  which  is  most  often  and  first  involved 
is  the  abdominal  cavity,  and  ascites  is  one  of  the  varieties  comiDaratively 
frequent  in  the  dropsies  of  pregnant  women.  Cazeaux  claims  that  hydram- 
nios,  hydrorrhoea  and  ascites  are  only  varieties  of  the  intra-abdominal 
serous  effusion.  We  cannot  accept  this  opinion.  Hydrorrhoea  and 
hydramnios  are  special  diseases,  as  we  hope  to  show,  and  although  it  is 
true  that  hydramnios  coincides  often  with  ascites,  there  are  a  number  of 
cases  in  which  ascites  exists  alone,  without  the  complication  of  hydramnios, 
showing  thus  the  possible  independence  of  these  two  dropsies.  Qi^dema 
only  arises  secondarily,  that  is  to  say,  when  the  disease  has  reached  a 
certain  stage;  while  ascites,  except  in  case  it  depends  upon  some  disease 
of  the  liver,  never  shows  itself  unless  the  oedema  becomes  general,  or  at 
least  has  taken  a  serious  form  or  in  some  manner  an  acute.  We  will 
return  to  it  in  the  study  of  hydrorrhoea  and  hydramnion  in  the  chapter 
on  the  diseases  of  the  ovum.  We  confine  ourselves  here  to  the  study  of 
ascites  during  pregnancy. 

Ascites. 

The  first  symptoms  of  ascites  manifest  themselves  sometimes  during 
the  first  months  of  pregnancy,  more  often  toward  the  fifth  or  sixth  month, 
rarely  later.  It  may  be  produced  slowly,  gradually,  or,  as  we  have  seen 
in  one  case,  rapidly.     In  this  last  case,  moreover,  the  quantity  of  effusion 


62  A   TREATISE    ON"    OBSTETRICS. 

into  the  abdominal  cavity  may  be  considerable,  and  if  tbe  effusion  ap- 
pears early,  there  may  be  a  marked  disproportion  between  the  size  of  the 
abdomen  and  what  it  should  be  at  that  period  of  gestation;  and  as,  on  the 
other  hand,  ascites  is  generally  complicated  by  general  oedema,  there 
results  a  period  of  ])ain  and  suffering,  which  only  goes  on  increasing  as 
the  disease  advances. 

The  effusion  goes  on  increasing  more  and  more  until  the  infiltration 
becomes  general;  the  patient  presents  a  puffy  appearance  which  gives 
the  face  a  pale,  livid  look.  The  abdominal  walls  are  greatly  stretched 
and  oedematous,  extremely  painful,  and  preserve  the  impress  of  the  finger. 
Cazeaux  compares  this  appearance  to  that  of  elephantiasis.  The  um- 
bilicus, enlarged  at  its  base,  forms  a  more  or  less  jDrominent  tumor,  which 
can,  according  to  Cazeaux,  acquire  the  size  of  a  hen's  egg;  but  this 
tumor  does  not  exist  constantly,  and,  in  one  case,  the  umbilicus  did  not 
form  such  a  tumor.  All  was  limited  to  an  enormous  distension  of  the 
umbilical  ring,  and  to  a  thinning  of  considerable  of  the  skin  in  the 
neighborhood. 

The  lower  extremities  and  the  greatly  swollen  genital  organs  increase  still 
more  the  woman's  suffering,  who  can  neither  stand,  sit  nor  keep  the  dorsal 
decubitus,  on  account  of  the  dyspnoea  and  pain  accompanying  respiration. 

If  we  try  to  palpate  the  abdomen,  the  extreme  sensibility  and  the 
enormous  distension  of  the  abdominal  walls  render  this  almost  useless. 
We  make  out  easily  dullness,  but  this  dullness,  contrary  to  that  which 
occurs  in  ordinary  ascites,  is  not  displaced  by  the  change  of  position  of 
the  patient. 

The  presence  of  the  uterus  changes,  indeed,  the  ordinary  conditions, 
and  as  Scarpa  has  pointed  out,  the  dullness,  slight  or  null  (in  the  hypo- 
gastric and  iliac  region)  is  very  pronounced  and  very  superficial  in  the 
left  hypochondriac  region. 

Fluctuation,  very  evident  in  certain  cases,  is  difficult  or  even  impossible 
to  perceive  in  others,  in  consequence  of  the  sensitiveness  and  distension  of 
the  abdominal  wall.  This  is  also  the  case  even  when  ascites  is  com- 
plicated with  hydramnion.  The  uterus  is  with  difficulty  made  out 
through  the  walls  of  the  abdomen.  Its  size  can  only  be  made  out  with 
much  difficulty,  the  foetal  parts  are  hard,  if  not  impossible  to  feel,  and, 
if  the  woman  at  this  time  perceives  foetal  movements,  these  are  dull  and 
obscure;  often  auscultation  gives  no  results. 

Depaul  has  nevertheless  given  two  signs  which  enable  us  to  recognize 
the  uterus:  first  its  abnormal  mobility;  this  seems  to  us  difficult  to  prove, 
but  there  is  another  sign,  which  is  of  great  importance.  It  is  this  fact, 
mentioned  by  Depaul,  which  has  been  to  us  in  one  case  a  great  help  in 
making  our  diagnosis,  that  when  the  abdomen  is  palpated  for  a  certain 
time  its  form  is  seen  to  change,  become  more  globular,  more  prominent. 


DISEASES   OF    PREGNANCY.  63 

and  at  the  same  time  forms  under  the  hand  a  hard,  globular  mass,  and 
one  can  with  difficulty,  it  is  true,  but  more  or  less  clearly,  appreciate  its 
size  and  form.  This  mass  is  no  other  than  the  uterus,  which  hardens  by 
the  fact  of  its  contraction.  [The  intermittent  uterine  contractions  of 
Braxton-Hicks.  — Ed.  ] 

When  the  effusion  is  moderate,  the  woman  only  experiences  a  feeling 
of  constraint,  of  general  fatigue  and  of  slight  oppression,  but  when  the 
effusion  becomes  great  enough  to  greatly  distend  the  abdomen,  the  pains 
become  severe,  depriving  the  woman  of  rest  and  sleep.  And,  moreover, 
as  the  effusion  progresses  rapidly,  fever  arises,  but  what  is  more  promi- 
nent is  dyspnoea,  which  may  go  on  to  complete  orthopnoea,  threatening 
the  woman  with  asphyxia,  syncope  and  serious  complication  from  the  side 
of  the  pulmonary  cavity. 

In  this  case  premature  labor  often  comes  on,  especially  if  the  woman 
has  passed  the  seventh  month,  but  unfortunately  it  is  not  always  so;  and 
particularly  in  the  case  where  ascites  is  large  in  amount  after  the  fifth 
month,  one  is  often  obliged  to  interfere.  At  other  times,  at  last,  the 
spontaneous  death  of  the  child  interrupts  the  course  of  the  disease;  the 
child  becomes  thus  a  foreign  body,  remaining  more  or  less  long  iu  the 
uterine  cavity  before  it  is  expelled.  It  is  understood  that  the  prognosis 
of  ascites  complicating  pregnancy  will  be  more  serious  as  it  makes  its  ap- 
pearance at  a  period  remote  from  full  term,  because  its  course  is  likely 
to  be  more  rapid,  and  it  will  also  be  complicated  with  hydramnion.  We 
will  return  again  to  this  subject. 

Aside  from  ascites,  serous  effusions  have  a  variable  influence  on  preg- 
nancy; most  often  pregnancy  follows  its  regular  course;  the  effusions 
may  disappear  some  days  before  confinement,  or  they  may  persist  to  that 
time.  Pregnancy  may  be  interrupted  prematurely,  or  more  rarely  the 
patient  may  die  before  labor  comes  on.  As  for  the  child,  it  may  be  born 
strong  and  well  developed,  but  it  may  also  be  born  prematurely,  or, 
finally,  it  may  die  during  pregnancy.  In  general,  delivery  leads  to  a  de- 
cided improvement  almost  immediately,  and,  at  the  end  of  some  days, 
everything  returns  to  its  normal  condition,  but  this  is  not  always  the  case. 

Treatment.  — When  the  dropsy  is  slight,  rest  and  simple  purgatives  will 
suffice  in  general,  associated  perhaps  with  tonics  and  iron  in  small  doses. 
But  when  the  dropsy  is  more  pronounced,  we  advise,  as  in  case  of 
dropsy  with  albuminuria,  a  milk  diet.  In  one  case  we  obtained  excellent 
results.  The  oedema  was  general,  but  without  effusion  into  the  serous 
cavities.  Cazeaux  rejects  absolutely  the  use  of  venesection  and  advises 
laxatives,  vapor  baths,  friction  and  diuretics,  l^ot  only  do  we  not  believe 
venesection  injurious,  but,  in  the  presence  of  congestion  in  such  cases,  we 
believe  that  it  is,  on  the  contrary,  perfectly  justifiable  to  a  moderate 
degree,  i.e.,  to  relieve  the  vascular  system  of  3000  to  4000  grains  of  blood. 

We  are  more  conservative  in  regard  to  punctures,  which  a  great  many 


64  A    TREATISE    ON    OBSTETRICS. 

authors  advise  us  to  make  on  the  labia  majora  and  the  lower  extremities, 
in  cases  in  which  the  oedema  is  very  marked.  The  vitality  of  the  tissue 
is  somewhat  modified,  and  the  punctures  may  become  the  point  of  origin 
of  gangrene.  We  are  inclined,  in  such  cases,  to  make  three  or  four  on 
each  extremity  and  far  apart.  With  Cazeaux,  we  do  not  advise  blistering 
and  irritating  the  skin.  It  is  especially  in  cases  of  pulmonary  congestion 
and  encephalitis  that  we  would  advise  blood-letting. 

Whenever  the  effusion  has  reached  the  visceral  cavities,  we  advise,  first 
and  foremost,  venesection,  together  with  a  milk  diet,  and,  if  these  means 
fail,  we  advise  paracentesis.  The  opcation  of  thoracentesis,  followed 
by  success,  without  the  interruption  of  pregnancy,  as  shown  by  Buguet 
in  cases  of  acute  pleurisy,  ought  to  encourage  us  to  perform  the  opera- 
tion in  cases  of  non-inflammatory  effusion  as  in  the  passive  effusion,  so 
to  speak,  of  serous  cachexia,  and  we  would  not,  for  our  part,  hesitate  to 
have  recourse  to  it.  But,  as  we  have  said,  the  serous  effusion  is  most 
commonly  in  the  peritoneal  cavity,  and,  in  view  of  imminent  asphyxia, 
paracentesis  should  be  resorted  to. 

As  Cazeaux  has  remarked,  the  enlarged  uterus  makes  it  impossible  to 
insert  the  trocar  in  the  place  usually  selected  in  ascites.  Scarpa  also,  in 
his  paper  on  pregnancy  complicated  with  ascites,  advises  that  the  punc- 
ture be  made  in  the  left  hypochrondriac  region,  between  the  upper  border 
of  the  external  oblique  muscles  and  the  borders  of  the  false  ribs,  in  order  to 
avoid  the  uterus,  the  puncturing  of  which  he  does  not  consider  as  serious  as 
Chambon  seems  to  think,  and  he  quotes,  in  regard  to  this  point,  the  cases 
of  Camper,  Langius,  Eeiscard  and  de  Nissi,  in  which  abortion  was  simply 
produced. 

In  a  case  of  ascites,  Langstaff,  as  cited  by  Cazeaux,  made  an  incision  two 
inches  below  the  umbilicus, to  expose  the  peritoneum,  which  he  pierced  with 
a  medium-sized  trocar,  but  forcing  it  very  slightly  so  as  not  to  wound  the 
uterus.  After  drawing  off  about  ten  pints  of  fluid, the  uterus  came  in  contact 
with  the  trocar,  which  gave  such  pain  that  it  had  to  be  withdrawn.  A  flex- 
ible sound  or  catheter,  introduced  between  the  uterus  and  the  anterior  sur- 
face of  the  peritoneum,  withdrew  the  rest  of  the  fluid.  Eight  hours  after 
the  operation,  peritonitis,  three  days  later  abortion,  recovery.  Ollivier 
d^ Angers,  in  a  case  in  which  the  umbilicus  projected  considerably,  opened 
this  with  a  scalpel,  a  watery  fluid  poured  out,  and  he  withdreAV  at  once 
twenty  pounds  of  fluid.  The  discharge  continued  for  twelve  days ;  on 
the  thirteenth  the  wound  closed;  twenty-eight  days  after  the  flrst  punc- 
ture it  had  to  be  repeated,  with  the  same  result,  and  twelve  days  later 
natural  labor  set  in,  with  the  birth  of  a  living,  though  feeble  child;  re- 
covery. 

When  pregnancy  is  not  far  advanced  paracentesis  is  the  only  resort,  but 
when  it  is  advanced  to  the  eighth  month,  or  further,  should  not  the  in- 
duction of  premature  labor  be  preferred  ?     Cazeaux  does  not  believe  in 


DISEASES    OF    PREGNANCY.  G5 

this,  because  he  thought  that  paracentesis  would  offer  sufficient  rehef,  so 
that  pregnancy  would  go  to  full  term  without  difficulty. 

We  think  Cazeaux  too  hopeful  on  this  point.  Paracentesis,  itself,  is 
not  always  harmless.  It  may  (as  the  case  of  Langstaff  proves)  give  rise 
to  peritonitis,  which,  on  the  one  hand,  may  induce  premature  labor,  and, 
on  the  other,  may  seriously  compromise  tlie  life  of  the  mother  and  child. 
Why  then  should  we  not  have  recourse  to  the  induction  of  premature  labor  ? 
Still  more  should  Ave  do  so  if  ascites  is  complicated  by  dropsy  of  the  uterus 
i.e.,  by  hydramnion. 

Pernicious  Anemia  of  Pregnajstcy. 

It  was  not  until  1871,  when  Gusserow  published  his  first  observations, 
that  the  pernicious  anemia  of  pregnant  and  puerperal  women  was  really 
demonstrated.  It  has  been  studied,  by  different  authors,  but  in  reality 
it  is  a  rare  disease,  as  the  small  number  of  observations  collected  up  to 
date  proves.  Batut  has  only  been  able  to  collect  a  dozen  well-authenti- 
cated cases. 

Etiology. — The  abode  of  the  woman,  the  manner  of  living  and  even 
the  climate  are  said  to  be  causes;  but  the  real  causes  are  pregnancy,  and 
the  functional  disturbances  which  accompany  the  condition  of  child-bear- 
ing; also  hemorrhages — in  a  word,  all  the  causes  which  tend  to  depress 
the  pregnant  woman,  which  are  summed  up  in  the  expression  physiologi- 
cal distress. 

Sijmpioms. — At  the  outset  it  is  generally  insidious;  and  it  is  only  m 
consequence  of  excessive  fatigue,  of  a  departure  from  the  usual  manner 
of  living,  that  the  patient  experiences  a  general  weakness,  which,  increas- 
ing rapidly,  confines  her  in  bed.  At  other  times,  it  is  on  account  of 
some  debilitating  cause,  abortion,  uncontrollable  vomiting,  diarrhoea,  that 
anemia  declares  itself,  and  this  especially  from  the  sixth  or  seventh  month 
of  pregnancy.  Sometimes,  as  in  the  cases  of  pernicious  anemia  of 
Thierry,  of  Lauth,  of  Stoltz,  it  is  only  after  labor  that  the  disease  appears, 
which  is  characterized  by  two  great  symptoms  or  phenomena,  i.e.,  the 
absence  of  albumin  in  the  urine,  and  a  considerable  diminution  of  the 
solid  constituents  of  the  blood,  and  particularly  of  the  haemoglobin,  which 
falls  as  low  as  10  in  1000. 

Then  the  face  becomes  colorless,  slightly  puffy,  the  tongue  is  dry 
but  not  coated,  and  fever  soon  appears,  which  is  accompanied  with  a  cer- 
tain amount  of  emaciation,  but  always  leaves  the  patient  in  a  fair  con- 
dition, which  persists  in  spite  of  a  certain  amount  of  digestive  trouble  not 
slow  in  showing  itself. 

We  are  always  impressed  with  the  general  feebleness  of  the  patient, 
which  renders  all  movement  difficult  and  painful,  and  this  is  accompa- 
nied by  headache,  dizziness,  vertigo  and  sleeplessness,  more  or  less  com- 
plete, and  above  all  by  violent  palpitations  and  dyspnoea,  with  a  tendency 
Vol.  IL— 5. 


Q6  A    TREATISE    OlST    OBSTETRICS. 

« 
to  syncope  on  the  least  effort  or  exertion.     The  syncope  increases  in 
severity  and  duration  according  as  the  disease  increases.     It  may  even 
become  fatal. 

On  auscultation,  the  heart  presents  a  systolic  souffle  more  or  less  strong, 
which  is  transmitted  into  the  vessels  of  the  neck.  The  seat  of  the  souffle 
is  not  fixed;  sometimes  at  the  apex  of  the  heart,  sometimes  it  is  percep- 
tible over  the  whole  cardiac  area;  as  a  rule  it  is  heard  at  the  base  of  the 
heart.  As  the  disease  advances,  the  souffle  becomes  dull,  and,  at  the 
same  time,  the  dyspnoea  becomes  worse,  and  there  are  disturbances  of 
vision,  the  conjunctiva  loses  its  color,  and  becomes  extremely  pale. 

This  condition  is  accompanied  by  dropsy,  at  first  localized  in  the  cellu- 
lar tissue  and  lower  extremities.  It  soon  becomes  general,  and  invades 
the  serous  cavities,  pleura,  pericardium,  peritoneum,  and  always  without 
albumin  in  the  urine.  Quinquaud  has  noticed  some  retinal  hemorrhages, 
but  they  are  rare. 

The  hemorrhages  which  frequently  appear  are  epistaxis  and  bleeding 
from  the  gums;  and,  at  the  same  time,  patients  are  tormented  by  neural- 
gic pains,  usually  facial  neuralgias. 

As  to  the  digestive  tract  we  observe  all  sorts  of  possible  troubles,  pyi'o- 
sis,  nausea,  vomiting,  cramps,  and  complete  anorexia.  Then  the  patient 
becom^es  prostrated,  more  or  less  completely,  the  pulse  is  feeble,  the  heart 
slow  and  feeble,  and  she  dies  exhausted.  In  certain  cases,  in  place  of 
this  rapid  and  progressive  course,  the  anaemia  becomes  chronic,  so  to 
speak,  with  intermissions  and  remissions,  more  or  less  marked.  These 
are  deceitful  because  they  inspire  the  hope  of  recovery  which  rarely  comes. 

Patliological  Anatomy. —  On  autopsy  nothing  characteristic  is  found, 
for  the  lesions  described  by  some  authors  are  met  with  in  other  morbid 
conditions. 

Treatment. — It  consists,  above  all,  in  regulating  the  diet,  but  this  is 
not  easy  to  do,  considering  the  difficulty  of  nourishing  and  sustaining 
the  patient.  Tonics,  iron,  etc.,  have  been  used.  Oxygen  has  been  re- 
commended, and,  finally,  Grusserow  has  used  transfusion,  as  also  has  Fer- 
rand.  It  has  failed  in  four  cases.  [In  this  pernicious  anemia,  arsenic 
frequently  serves  a  better  purpose  than  iron.  Further,  the  bin-oxide  of 
manganese,  an  excellent  blood  regenerator,  might  be  tried.  —Ed.] 

Considering  the  severity  of  the  disease,  is  one  authorized  to  induce 
premature  labor  or  abortion? 

This  question  we  answer  in  the  affirmative;  the  interest  of  the  mother 
precedes  all  other  considerations.  We  should  not  interfere  too  soon  or 
too  late,  and  it  is  the  condition  of  the  mother  alone  which  can  indicate 
the  proper  time  to  interfere.  This  will  not  always  save  the  patient,  for, 
in  a  number  of  cases,  the  pernicious  anemia  began  after  confinement. 
We  must  look  to  the  future  to  settle  this  grave  question. 


diseases  of  pregistancy.  67 

Lesions  of  the  Secretions  and  the  Excretions. 
Ptyalism. 

Excessive  salivation,  or  ptyalism,  is  not,  in  pregnant  women,  as  rare 
or  insignificant  a  symptom  as  Cazeaux  seems  to  think.  Besides  the 
inconvenience  and  discomfort  which  it  brings  upon  the  pregnant  woman, 
it  weakens  her  considerably,  interrupts  assimilation,  induces  a  certain 
amount  of  depression,  which  leads  to  emaciation  and.  a  tired  feeling, 
sometimes  very  marked.  It  is  true,  the  health  of  the  woman  is  not,  in 
general,  seriously  undermined;  but  ptyalism  none  the  less  merits  the  at- 
tention of  the  physician.  Sometimes  it  may  be  accompanied  by  vomiting, 
sometimes,  on  the  contrary,  it  may  exist  alone.  Slight  in  some  women,  in 
others  it  becomes  very  abundant,  even  in  the  night,  and  deprives  the  patient 
of  a  certain  amount  of  sleep.  According  to  Cazeaux,  it  may  be  a  temporary 
affair,  in  general  of  slight  duration.  The  cases  of  serious  and  abundant 
salivation  we  have  had  do  not  allow  us  to  share  this  opinion.  In  7  cases 
the  ptyalism  began,  so  to  speak,  with  pregnancy  (3  times  in  the  same 
woman),  and  persisted  after  the  pregnancy,  once  15  days,  once  18  days, twice 
for  2  to  3  weeks,  and  3  times  in  the  same  woman  for  3  to  4  months  after 
labor.     Cazeaux  himself  has  had  similar  cases. 

Unfortunately,  the  means  of  treating  the  disease  are  of  little  avail. 
Astringent  gargles,  sugar,  ice,  have  usually  failed.  That  which  has 
the  most  power,  and  still  its  power  is  limited,  is  the  use  of  bitter  sub- 
stances, quassia,  dry  bitter  orange  peel,  (of  which  the  patient  can  keep  a 
small  piece  always  in  the  mouth,)  brandy,  used  as  a  gargle  several  times 
a  day.  We  have  never,  as  Cazeaux,  seen  ptyalism  cease  toward  the  end 
of  pregnancy,  but  have  seen  it,  on  the  contrary,  persist  even  to  the 
end  of  that  pregnancy,  and  appear  again  in  the  same  woman  in  three  suc- 
cessive pregnancies. 

Gingivitis  of  Pregnancy. 

This  disease  is  characterized  by  a  redness,  a  congestion  of  the  gums  on 
both  maxillas,  a  pufiiness  which  covers  a  part  of  each  tooth,  and  forms 
thus  a  pad,  more  often  on  the  anterior  of  both  maxilla  as  far  as  the  molar 
teeth.  This  pad  of  gums  bleeds  easily,  the  teeth  become  loose,  shaky, 
and  may,  later  on,  fall  out  of  their  sockets.  Then  results  a  difficulty 
in  mastication  which  becomes  the  more  painful  as  the  lesion  is  more 
pronounced. 

Pinard  in  73  women,  of  whom  43  were  multiparse  and  32  primiparae, 
found  it  31  times  in  primiparae  and  14  times  in  multiparje.  Multiparse 
are,  then,  more  liable  to  this  disease  than  primiparae.  Former  pregnancies 
and  bad  general  condition  appear  to  play  an  important  part  in  the  course. 
Gingivitis,  as  a  rule,  continues  through  pregnancy  and  only  disappears  a 
month  or  two  after  confinement.     It  persists,  sometimes,  longer  in  women 


68  A    TREATISE    OIN"    OBSTETEICS. 

who  nurse.  We  have  at  present  under  observation  a  young  woman  m 
the  seventh  month  of  her  pregnancy^  who  presents  not  only  this  gingivitis, 
but  a  time  gingival  tumor  of  the  size  of  an  almond,  situated  near  the  left 
canine  tooth.  The  tumor  is  a  bloody,  fungoid  tumor,  which  resists  all 
treatment.  Tincture  of  iodine,  glycerol  of  tannin,  chlorate  of  potash,  rec- 
ommended by  Pinard,  have  failed;  chromic  acid  alone  relieved  the  patient, 
but  did  not  produce  a  cure,  which  will  probably  occur  after  confinement. 
The  following  solution,  chloral  and  alcohol  equal  parts,  advised  by 
Pinard,  has  failed  completely. 

Excretion  of  Urine. 

The  secretion  of  urine  during  pregnancy  is  the  same  as  in  the  non- 
pregnant state.  It  is  neither  increased  nor  diminished.  But  it  is  not 
the  same  with  the  excretion,  which  suffers  marked  modifications.  At 
times  there  is  retention,  sometimes  incontinence,  and  finally  an  incessant 
desire  to  urinate,  occurring  at  different  periods  of  pregnancy.  These 
troubles  may  be  referred  to  various  causes,  and  in  regard  to  incontinence, 
in  particular,  it  may  be  observed  in  two  distinct  conditions.  Sometimes 
it  may  succeed,  or,  better,  accompany  retention — that  is  to  say,  an  incon- 
tinence by  distension;  on  the  other  hand,  there  may  be  no  retention; 
but,  in  multiparse  in  particular,  the  vesical  sphincter  has  lost  some  of  its 
tonicity,  and  in  walking,  coughing,  laughing,  lifting,  such  women  eject 
a  small  amount  of  water,  which  the  bladder,  having  lost  its  retentive 
power,  is  unable  to  hold.  There  may  be  a  true  inflammation  of  the  blad- 
der, cystitis,  pains,  malaise,  frequent  micturition. 

It  is  the  grouping  of  all  these  urinary  troubles,  (not  included  in  albu- 
minuria), which  Monod  and  Terrillon  have  studied  lately  with  great  care, 
and  both  have  shown  that  they  are  much  more  frequent  than  one  would 
suppose.  Thus  Monod,  on  questioning  124  primiparge  or  multiparae,  not 
ouly  as  regards  the  existence  of  the  urinary  trouble,  but  also  as  to  the 
pain,  the  frequency,  and  the  time  of  the  appearance  of  the  trouble,  has 
found  that  in  4  cases  the  vesical  symptoms  have  shown  themselves  at  the 
beginning  of  pregnancy  in  33  women  out  of  131  cases.  Here  are  the 
observations  taken  of  124  Avomen: 

Women  who  did  not  suffer  from  urinary  troubles  in  any  period  of 
pregnancy,  61. 

Women  having  urinary  symptoms,  63. 

Women  who  had  frequent  micturition  in  the  last  two  or  three  months, 
or  rather  in  the  last  four  months  of  pregnancy,  37. 

Women  having  vesical  symptoms  during  the  first  weeks,  26. 

Of  these  26  women,  frequent  desire  to  urinate  only,  11;  frequent  and 
painful  micturition  and  complicated  by  haematuria,  15.  Among  the  26  cases 
of  urinary  troubles  at  the  beginning  of  pregnancy,  16  were  primiparse, 
10  multipara.     To  these  figures   must  be  added  seven  cases  of  Monod, 


DISEASES    OF    PREGNANCY.  69 

and  we  have  the  following  total  of  cases  in  which  the  urinary  troubles 
began  at  the  commencement  of  pregnancy:  Number  of  women,  131; 
with  urinary  trouble,  33. 

The  causes  of  these  troubles  are,  1st.  Mechanical.  2d.  Inflammatory. 
They  occur  not  only  during  pregnancy  but  more  frequently  after  con- 
finement. They  are  due  to  pressure  exerted  by  the  foetal  head  on  the 
base  of  the  bladder,  and  to  obstetrical  operations,  and  are  the  product  of 
true  inflammatory  lesions,  which  may  produce  sloughs  or  fistulo9.  But 
during  pregnancy  there  is  one  cause  more  important  than  all  others,  the 
pressure  exerted  by  the  gravid  uterus,  which  causes  retention,  and  all  the 
sequeke  more  or  less  severe  which  accompany  it. 

Monod  rightly  distingaishes  four  cases;  1st.  Retention  during  preg- 
nancy; 2d.  Cystitis  beginning  at  the  commencemeut  of  pregnancy;  3d. 
Cystitis  after  the  puerperal  period;  4th.  Cystitis  independent  of  the 
puerperal  state,  but  dependent  upon  uterine  influences. 

1.  Retention  during  Pregnancy. — The  chief  cause  is  retroversion  of  the 
gravid  uterus.  We  only  mention  it  here,  and  treat  of  it  at, length  in  a 
special  chapter.  We  will  say  here,  that  it  may  become  the  cause  of 
cystitis  more  or  less  severe,  and  can  go  on  to  the  exfoliation  of  the  vesical 
mucous  membrane,  (Wardell,  Spencer  Wells,  Wittich,  Philips,  White- 
head-Haussman,  Moldenhauer,  Schatz,  etc.).  Finally,  Playfair  has  re- 
ported a  case  in  which  retention  was  due  to  a  mal-position  of  the  foetus — 
transverse  position. 

2.  Cystitis. — But  there  is  another  cause  of  urinary  troubles  which  declares 
itself  in  the  first  weeks  of  conception,  and  which  is  independent  of  all  the 
ordinary  causes  of  vesical  inflammation.  This  cause  of  urinary  troubles, 
mentioned  by  Terrillon,  Ollivier,  Hervieux,  Madame  Puejac  of  Montpel- 
lier,  is  simple  cystitis,  which  may  be  accompanied  by  slight  frequent 
micturition  or  dysuria,  or  acute  pain,  or  haematuria,  or  even  by  abor- 
tion, as  in  Ollivier's  case. 

Cystitis,  according  to  Monod,  may  be  the  result  of  passive  hypergemia 
of  the  vessels  which  supply  the  bladder  and  uterus,  accompanying  those 
uterine  congestions  which  occur  at  the  beginning  of  pregnancy.  It  is 
not  of  special  importance,  except  in  regard  to  the  conditions  causing  it. 

Mens  has  already  mentioned  cystitis  of  the  first  month  of  pregnancy, 
which  he,  with  Churchill,  attributes  to  a  vesical  catarrh,  produced  by 
reflex  irritation :  after  the  second  month  it  is  to  be  attributed  to  irritation, 
to  pressure  of  faecal  matter,  the  result  of  constipation,  and  also  to  retrover- 
sion. 

He  acknowledges  several  varieties  of  cystitis,  and  mentions  the  fact  that 
Tillaux,  Parent,  Rlchet  have  reported  cases  of  varicose  cystitis  or  hemor- 
rhoids of  the  bladder.  Aside  from  this  kind  of  cystitis,  he  mentions  two 
varieties  which  he  calls  post-puerperal  cystitis.  One  is  produced  only 
by  traumatism  during  confinement,  the  other  is  idiopathic,  and  may  be 


70  A   TREATISE    ON   OBSTETRICS. 

produced  after  abortion,  after  a  normal  labor,  and  may  disappear  almost 
immediately  after  confinement,  or  more  slowly  (six  weeks  according  to 
Monod,  Grueneau  de  Mussy,  Hervieux,  Olshausen,  Kaltenbacli,  Voille- 
mier,  etc.).  Finally,  he  mentions  cystitis  in  women  independent  of  the 
puerperal  state,  but  not  treated  of  here,  and  he  arrives  at  the  following 
conclusions: 

1st.  Urinary  symptoms,  in  pregnant  women,  arise  from  two  different 
causes,  and  to  each  are  attached  a  distinct  group  of  clinical  symptoms.  One, 
the  pressure  of  the  gravid  uterus  which  produces  retention,  the  other 
vesical  congestion,  which  is  explained  by  the  vascular  connection  between 
the  uterus  and  bladder,  and  which  produces,  in  the  latter  organ,  a  predis- 
position to  inflammation.  2d.  An  acute  cystitis,  which  is  manifested 
during  the  first  weeks  of  gestation.  3d.  Cystitis  observed  immediately 
after  or  in  the  first  weeks  following  a  normal  labor,  which  is  called  post- 
puerperal  cystitis  on  account  of  the  time  of  its  appearance.  4th.  The 
anatomical  relation  and  vascular  connection  between  the  uterus  and  the 
bladder  accounts  for  the  frequency  with  which  urinary  troubles  accom- 
pany a  great  many  diseases  of  the  uterus,  even  under  certain  physiological 
modifications  of  this  organ  during  menstruation  or  at  the  menopause,  for 
example. 

There  are,  then,  certain  inflammations  of  the  bladder  peculiar  to  women, 
and,  contrary  to  the  common  opinion,  cystitis  is  far  from  being  rare. 

Terrillon  has  reported  a  number  of  analogous  cases,  and  the  discussion 
of  the  subject  (]  880)  in  the  Surgical  Society,  allowed  several  surgeons  to 
increase  the  number  of  observations. 

Albuminuria- 

Albuminuria,  albuminuria  of  Piorry,  Bright's  disease,  consists,  Jaccoud 
says,  in  a  disturbance  of  the  renal  secretion,  characterized  by  the  presence 
of  albumin  in  the  urine.  Considered  from  the  standpoint  of  pregnancy,  it 
may,  according  to  Dumas,  be  presented  under  two  very  different  forms: 
"  One,  which  is  entirely  and  intimately  dependent  upon  pregnancy  itself, 
the  other  independent  of  it,  for  its  primary  cause;  but  wliich,  by  the 
fact  of  its  being  coincident  with  pregnancy,  follows  a  definite  course,  and 
apart  from  its  origin,  develops  under  its  influence  as  the  preceding. 

"Physiological  pregnancy,  by  modifying  the  quality  and  quantity  of  the 
blood,  is  a  predisposing  general  cause  of  albuminuria.  But  to  produce 
the  last,  a  cause  must  be  added,  and  this  may  be  due  to  a  true  patho- 
logical state  of  the  blood,  a  morbid  condition  of  the  kidney,  an  acci- 
dental cause,  or  mechanical  pressure  exerted  by  the  uterus,  when  it  has 
acquired  a  sufficient  size.  The  influence  of  labor  may  be  similar  to  the 
mechanical  pressure  at  the  end  of  pregnancy;  but  it  can  only  produce 
this  effect  when  the  predisposing  cause  has  exercised  its  previous  influ- 
ence.    Finally,  a  woman   may  become   pregnant  when  she  already  has 


DISEASES    OF    PREGNANCY.  71 

albuminuria.  In  this  case  there  is  a  double  influence  to  consider,  one  ex- 
erted by  the  albuminuria  on  the  pregnant  woman,  and  the  other  the 
influence  of  pregnancy  on  albuminuria,"' 

The  conclusions  of  Dumas  only  confirm  the  opinion  of  Tarnier,  who 
rightly  admits  that  the  albuminuria  of  pregnancy  alone  can  no  longer 
be  regarded  as  a  symptom  of  a  single  lesion,  but  that  the  passage 
of  albumin  in  the  urine  depends,  on  the  contrary,  upon  very  different 
causes.  We  shall  see  in  the  section  on  pathogeny  how  many  theories 
this  question  of  albuminuria  has  raised.  However  it  is,  we  can,  with 
Dumas,  state  it  as  settled,  that  three  conditions  are  necessary  for  the 
normal  secretion  of  urine.  1st.  A  normal  distribution  of  the  generated 
fl.uid,  or  the  mechanical  integrity  of  the  circulatory  system;  2d.  A  normal 
condition  of  the  blood;  3d.  A  normal  filtration  or  anatomical  and  func- 
tional  integrity  of  the  kidney. 

But  these  three  conditions  not  being  met  with  in  pregnant  women, 
hence  the  possibility  of  albuminuria.  Moreover,  albuminuria  may  have 
existed  before  pregnancy.  Finally,  albuminuria  may  show  itself  only 
during  labor. 

Hence  the  division  admitted  to-day  by  almost  all  authors:  1st.  Albumi- 
nuria in  pregnant  women,  Avith  pre-existing  renal  lesions;  2d.  Idiopathic 
albuminuria;  3d.  Albuminuria  complicating  labor. 

Albuminuria  of  Pregnancy  with  Pre-existing  renal  Lesions, 

Pregnancy  may  occur  in  women  having  renal  lesions  before  they  be- 
come pregnant,  and  these  lesions  may  or  may  not  have  been  suspected. 
Bright's  disease  in  these  cases  develops  more  rapidly  and  yields  more 
quickly  to  pathological  manifestations.  Under  the  infiuence  of  pregnancy 
renal  lesions  may  increase  more  and  more,  and  produce,  Bamberger  says, 
in  a  short  time,  marked  and  incurable  disorders.  Pregnancy  becomes  a 
powerful  auxilliary  cause,  and  Dickinson  has  given  an  exact  picture  of 
the  progress  of  the  disease. 

"  When  the  renal  disease  advances  with  pregnancy,  it  rarely  attains  a 
serious  stage  during  the  first  gestation.  Women  may  die,  it  is  true,  in 
eclampsia,  but  if  they  live,  little  by  little  the  oedema  will  disappear,  the 
urine  will  cease  to  be  albuminous,  and  they  will  enjoy  perfect  health  until 
the  next  pregnancy,  which  will  lead  to  some  accident.  The  oedema  will  then 
increase  considerably;  the  patient  will  be  more  exposed  to  eclampsia,  the 
complication  will  be  slower  in  disappearing  after  confinement,  and  thus, 
at  each  new  pregnancy,  the  renal  symptom  will  become  more  chronic, 
until  the  albuminuria  continues  between  the  pregnancies,  and  the  patient 
will  then  be  exposed  to  all  the  complications  which  accompany  granular 
kidneys." 

Hypolitte,  who  has  reported  a  case,  proves  that  in  these  cases  albumi- 
nuria does  not  disappear  from  the  urine,  but  persists  until  Bright's  disease 


72  A  TREATISE    ON    OBSTETRICS. 

has  run  its  course  in  one  way  or  another.  But  in  these  instances,  as  he 
has  observed,  the  convulsions  are  not  those  of  albuminuria  gravidarum; 
they  are  ura^mic  convulsions  and  not  eclamptic,  and  it  is  easy  to  make  a 
diagnosis  by  taking  the  temperature,  the  appearance  of  uraemia  and 
eclampsia  differing  essentially  as  we  shall  see. 

True  Albuminuria  Gravidarum. 

Albuminuria  is  far  from  being  a  rare  disease,  at  least  so  the  following 
statistics  show: 

Blot       among  205  women  nine  months  pregnant,    41  times. 
Hypolitte    "       165        "  "  "  '"  32       " 

Independent  of  labor,  32  cases,  .       10       " 

Meyer  106        "  *>         .'  .6      " 

36  in  labor  and  puerperal  state       .       31       " 
Litzmann,    ,         37  "      "  "  "  "         .       16       " 

Abeille, 10  per  cent,, 

Moricke,       .       20       .         .         .         •        .         .         .         1  case. 
Petit,     .         .     1-13       .         .         .         .        .         .        .29  cases. 

Dumas,  who  has  collected  all  these  statistics,  gives  1  in  5  or  6. 

As  to  age.  Devil! iers  and  Eegnault  have  fixed  upon  from  17  to  38  years, 
or  from  17  to  30  years,  as  the  period  when  the  disease  is  most  often  seen. 
Bailly,  on  the  contrary,  attaches  only  a  secondary  importance  to  age.  It 
is  necessary,  however,  to  take  into  account  these  statistics  and  those 
furnished  by  Peter,  Avliich  seem  to  indicate  that  albuminuria  is  more 
common  in  young  women  than  in  older  ones. 

Among  113  Avomen,  of  which  27  were  suffering  from  albuminuria,  Peter 
found: 


Age. 

No.' 

Albuminuria, 

15  to  20  years. 

19 

6 

21  "  26      "       . 

46 

11 

26  "  30      " 

28       .  , 

6 

31  "  35      "       . 

13 

1 

36  "  37      "       . 

6 

8 

42      "       . 

1 

0 

Ought  we  not  here  to  refer  it  to  primiparity  rather  than  to  age,  since 
it  is  more  common  as  the  women  are  younger  ? 

The  influence  of  primiparity  is,  indeed,  indisputable,  and  it  is  acknowl- 
edged by  all  authorities,  thus: 

-ry,  ,  j  Primipara,      99      Albuminuria,  30 

^^^^'  \  Multipara,    106  "  11 

Moricke,  13  cases,     i -vr  n--  a  o 

'  '      (  Multipara,  3 

n  x-j.   010  i  Primipara,     52  "  13 

Petit,  212  women,     i  ^vr   i,-^  an  a  no 

'  '     {  Multipara,     60  13 

Rare  during  the  first  months,  albuminuria  is  noticed  above  all   after 


DISEASES    OF    PREGNANCY.  73 

the  sixth  month  and  during  labor.     There  have  been  reported,  however, 
a  number  of  cases  of  early  albuminuria.     These  have  been  observed  by: 


Ollivier,  .  .  at  3  month;: 

Depaul,  .  .  "    G 

Bernheim,  .  "7         " 

Petit,       . 


Bach,     .         .         .         at  G  weeks. 
Cazeaux,         .         .  ''4:  months. 

Cohen,  .         .  "b       " 

In  Tlu'rapeutic  Bulletin, "  5^     ' ' 
Devanet,         .         .         "  G        " 

We  have  seen  a  case  at  six  months  and  a  half  in  a  multipara  who  had 
shown  it  in  two  previous  pregnancies,  one  of  Avhich  was  complicated 
with  eclampsia. 

AYliat  are  the  causes  of  albuminuria  in  pregnancy?  The  causes  which, 
theoretically,  produce  albuminuria  may  be  reduced  to  three:  1.  Alteration 
in  the  blood,  super-albuminous.  2.  Excess  of  intra- vascular  tension, 
(the  hydremic  state  of  pregnant  women. )  3.  Temporary  or  permanent 
disorder  of  the  kidneys. 

1st.  Supe?^- Albuminous  Blood.  — This  theory  is  based  on  the  experiments 
of  CI.  Bernard,  who  produced  albuminuria  by  injecting  into  the  veins 
a  certain  quantity  of  albuminous  liquid;  on  the  experiments  of  Schiff,  of 
Stokvis,  who  showed  that  the  development  of  artificial  albuminuria  is  de- 
pendent upon  the  molecular  state  of  the  albumin  injected;  on  the  influ- 
ence of  exclusive  albuminous  diet.  (CI.  Bernard,  Bareswell,  Brown- 
Sequard,  Tessier,  Hammond).     Gubler  has  proposed  the  following  theory: 

"  During  pregnancy  the  mother's  blood  should  furnish  the  foetus  with 
material  for  nutrition,  but  only  in  a  soluble  and  diffusible  form,  since 
there  is  no  communication  between  the  foetal  and  maternal  surfaces  of  the 
cotyledons  of  the  placenta. 

"There  are,  in  consequence",  various  forms  of  albumin  which  are  called 
upon  to  nourish  the  new  being,  and  during  this  time,  the  maternal  organ- 
ism must  provide  for  a  double  Avaste  by  absorbing  more,  by  a  more  strict 
economy  of  the  proteid  elements,  or  indeed  by  these  two  causes  together. 
A  greater  quantity  of  these  materials  must  be  found  ready  at  hand.  It 
is  enough  that  by  virtue  of  a  simple  change  in  the  mode  of  respiratory 
combustion  the  ternary  substances  should  be  consumed,  and  that  the  albu- 
minoid materials  escaping  the  catalytic  action  of  the  liver,  the  direct 
changes  in  the  capillaries  should  be  entirely  reserved  for  the  role  of  plas- 
tic alimentation. 

"Now,  by  this  new  way  of  working,  a  system  badly  regulated  or  new 
may  go  beyond  the  mark,  and  the  albumin  becomes  relatively  excessive 
for  the  wants  of  the  two  organisms  grafted  one  on  the  other. 

"This  is  the  easier,  since  the  albumin  which  has  passed  through  the  foetus 
without  being  employed  in  its  development  comes  back  loaded  with  waste 
material,  since  respiration  is  not  yet  established  in  the  latter,  whose  urine 
normally  contains  albumin,  as  in  batrachians,  and  never  contains  urea. 
Besides,  this  albumin,  as  a  whole,  has  returned  iiito  the  circulation  of  the 


74  A   TREATISE    ON    OBSTETRICS. 

motlier,  seeing  that  the  renal  secretion,  not  appearing  outside,  is  nearly 
suppressed  during  intra-uterine  life.  Albuminuria  in  pregnant  women 
thus  implies  an  over-production  of  albuminoid  substances,  considering 
the  wants  of  the  two  organisms. 

"  At  times  the  mother  produces  too  much,  sometimes  the  foetus  does 
not  consume  enough;  at  other  times  the  two  causes  Join  in  producing 
'the  result. 

"If  these  products  increase  with  weight  and  dimensions,  one  may  con- 
clude that  the  albuminuria  is  produced  by  organic  disorders  in  the  mother. 
If  an  albuminuric  mother  gives  birth  to  a  weak,  sickly  child,  there  is 
ground  for  assuming  the  want  of  development  of  the  latter  as  having 
occasioned  an  excess  of  albumin  in  the  blood  and  in  the  urine/' 

As  Hypolitte  remarks,  if  this  theory  is  admitted,  albuminuria  should 
be  met  almost  constantly  in  pregnancy,  but  it  is  not,  and,  what  is  more, 
this  theory  does  not  explain  the  albuminuria  of  the  first  months  when  the 
nutrition  of  the  foetus  is  very  slight.  Finally,  the  sudden  disappearance 
of  albuminuria  after  confinement  in  some  cases  could  not  be  thus  ex- 
plained; and  again,  children  who  are  born  of  women  suffering  from  albu- 
minuria do  not  appear  much  more  sickly  than  others.     Thus: 

Weight.  Cases. 

Blot,  in  32  cases  of  albuminuria,  Twins,  together,  12  pounds.     1 

Children  more  than     ?|-         "  5 

"       from         7ito6|    "        20 
"       less  than        6f         "  6 

Depaul,  in  13  cases  at  term  : 

Weight.  Cases. 

A-lbuminuric  and  eclampsic,  from  9    to  8|-  pounds.  2 


73,   ' 

'  6|        ' 

4 

4 ' 

'  5|        ' 

5 

H  ' 

'  ^    ' 

2 

Showing,  in  a  total  of  56  children,  39  were  of  an  average  weight  or  above, 
and  17  only  below. 

Petit  in  93  cases,  49  being  boys  and  44  girls,  found  22  cases  of  albumi- 
nuria, 11  boys,  11  girls.  Eleven  times  the  weights  were  taken  carefully 
and  there  were  found, 

Weight.  Cases. 

Between  8|- — 7f  pounds,      3 
7|-6|        "  4 

6|— 5|        "  2 

"  K'A 4.3  "  9 

The  average  weight  of  each  infant  ax  term  was  from  7|-  to  6|-  pounds. 

Cassin  does  not  admit  this,  since  he  has  found  that  children  born  of 
albuminuric  mothers,  weigh  less  than  others,  where  the  condition  does 
not  exist.     He  believes  in  the  depressing  influence  of  albuminuria. 


DISEASES    OF    PKEGNAlSrCY.  75 

Eobin  admits  that,  in  pregnant  women,  li^matosis  is  incomplete.  This 
predisposes  to  an  hydrajmic  state  of  the  blood,  and  the  relaxation  of  the 
tissues;  and  facilitates  and  explains  the  passage  of  albumin  into  the  urine, 
which  impoverishes  the  blood  and  tends  to  increase  its  fluidity. 

2d.  Excess  of  Intra-Vascular  Tension. — Beau  and  Cazeaux,  relying  on 
the  analyses  of  Andral  and  Gavarret  and  Becquerel  and  Rodier,  first  pro- 
pounded the  theory  of  the  existence  of  a  serous-plethora  in  chlorosis  and 
pregnancy.  This  plethora  necessitates  an  increased  arterial  tension, 
which  causes  the  passage  of  albumin  into  the  urine. 

Upheld  by  Mangenest,  Devilliers  and  Regnault,  Eobin  and  Ve^'deil, 
Bouillaud,  Potain,  Gregory,  Johnson.  Simon,  Briiun,  Anderson,  Finger, 
Gallo,  Calderini  and  by  Mosier,  Kierulf .  Herman,  Stokvis,  who  have  shown 
that  an  excess  of  water  alone  in  the  blood  can  produce  albuminuria,  by 
interrupting  the  equilibrium  existing  between  the  plasma  and  the  globules, 
and  adding  the  albumin  of  the  latter  to  the  serum,  this  theory  has 
been  taken  up  lately  in  a  masterly  way  by  Peter,  who  has  given  it  the 
name  of  serumuria. 

"Even  as,"  Peter  says,  "the  pregnant  woman,  f  or  the  hgematosis  and  the 
hsematopcesis  of  the  foetus,  makes  the  materials  for  both,  even  so  she  per- 
forms the  urinary  functions  for  both. 

' '  The  pregnant  woman  excretes  daily  a  greater  quantity  of  urine.  While 
the  woman  in  a  normal  state  eliminates  from  330  to  360  grains,  Quinquaud 
has  shown  that  of  urea,  the  pregnant  woman  eliminates  from  450  to  600 
grains,  i.e.,  nearly  one  and  a  half  to  twice  more  than  in  the  unimpreg- 
nated  state.  If  she  thus  makes  more  urine  in  twenty-four  hours,  she 
ought  to  do  more  excretory  work,  i.e.,  more  blood  should  be  filtered  by 
the  kidneys,  the  greater  the  functional  hyperemia.  But  the  more  the 
blood  in  the  organ  the  greater  the  vascular  pressure,  and  the  greater  the 
vascular  pressure  the  more  the  filtration,  not  only  of  the  serum  of  the 
blood,  but  even  of  the  blood  itself,  a  phenomenon  which  is  improperly 
called  albuminuria,  but  which  is  serumuria." 

Moreover  the  kidney  has  a  functional  relation  with  the  uterus,  which 
has  been  established  by  Buquet.  This  author  has  noticed  the  enlarge- 
ment of  the  kidneys  at  the  catamenia,  in  a  case  of  ectropion  of  the  organs. 

Finally,  the  renal  arteries  give  passage  to  a  large  amount  of  blood, 
which  congests  the  utero-ovarian  arteries  very  much  during  pregnancy; 
hence  the  dilatation  of  the  renal  vessels  and  the  increase  in  the  hyperEemia 
of  those  organs. 

Blot  had  already  pointed  out,  as  a  cause  of  albuminuria,  the  active  and 
passive  congestion  of  the  kidneys,  and  a  sympathetic  nervous  irritation  of 
the  organs,  on  account  of  the  relation  which  exists  between  them  and  the 
uterus,  and  which  produces  albuminuria,  just  as  irritation  of  the  pneumo- 
gastric  produced  it  in  the  experiments  of  Claude  Bernard. 

Martin  admits  a  direct  relation  between  the  kidneys  and  uterus.    Every 


76  A   TREATISE    ON    OBSTETRICS. 

increased  stimulation  of  the  uterine  sympathetic  system  will  react  on  the 
renal,  and.  produce  albuminuria. 

Blot,  and  some  other  authors,  have  added,  as  a  cause  of  blood  pressure, 
the  mechanical  action  of  the  uterus,  which  presses  on  the  great  vessels  of 
the  abdomen,  and  impedes  thus  the  return  circulation. 

Frerichs,  Braun,  Rosenstein,  Wieger,  Beckmann,  Krassing,  Brown- 
Sequard,  Jaccoud,  Rose  Cormak,  Barker,  Correnti,  Molas,  Mohammed, 
Moricke,  Hubert  de  Louvain,  have  accepted  this  last  theory. 

It  is  impossible,  indeed,  to  deny  this  action  of  the  uterus  in  the  last 
months  of  pregnancy,  but  if  it  is  true  that  albuminuria  is  most  often  met 
with  in  this  period  it  is  none  the  less  true  that  it  is  sometimes  very  often 
met  with,  so  to  speak,  at  a  period  when  it  is  impossible  to  refer  it  to  the 
pressure  of  the  uterus.  We  are  forced,  therefore,  to  look  for  another 
cause,  and  that  of  Peter  seems  the  most  rational. 

This  theory  of  Peter  has  lately  been  urged  by  Moricke:  "  The  stasis  of 
the  blood  is  the  cause  and  origin,  for  the  most  part,  of  nephritis  in  preg- 
nant women.  This  stasis  acts  in  two  ways:  first,  causing,  as  Peter  says, 
a  renal  hypersemia;  second,  alterations  in  the  blood.  We  know,  from 
modern  research,  that  want  or  lack  of  oxygen  is  the  cause  which  produces 
fatty  degeneration  of  the  kidneys.  The  intra-abdominal  pressure  being 
increased  during  pregnancy  (aside  from  the  direct  pressure  exercised  by 
the  gravid  uterus  on  the  renal  vessels),  produces  an  obstacle  to  the  return 
of  venous  blood  to  the  kidneys.  The  circulation  is  not  increased  in  the 
kidneys,  but  diminished  notably;  a  less  number  of  red  globules  pass  in  a 
given  time  than  in  the  normal  state.  (These  red  corpuscles  are,  on  ac- 
count of  the  pregnant  state,  less  numerous).  Consequently,  the  quantity 
of  oxygen  which  is  taken  from  these  globules  by  the  tissues  is  diminished 
in  amount.  There  results,  then,  disturbances  of  nutrition  and  fatty  de- 
generation. Would  tliis  condition  of  the  blood  predispose  also  to  inflam- 
matory changes?  This  seems  probable,  according  to  Nasse,  who  says: 
"  up  to  the  present,  the  uterine  lymphatics  have  not  been  studied  in 
pregnant  animals,  but  it  is  very  possible  that  they  may  play  some  part 
in  renal  inflammation,  and  even  the  change  in  the  blood  in  pregnancy  is 
analogous,  in  a  general  way,  to  that  which  exists  in  cases  of  renal  inflam- 
mation.^' 

Bailly  rejects  this  explanation,  for  he  thinks  that  serous-poly^mia  is  a 
theoretical  rather  than  a  real  state  of  the  blood,  and,  although  certain 
eclampsic  women  are  pale  and  anemic,  others,  apparently  strong  and  vig- 
orous, are  none  the  less  victims  of  the  disease. 

ord.  Tenqjorary  or  Permanent  Kidney  Disease. — In  other  words.  Can 
pregnancy  become  the  cause  of  renal  lesions  ? 

We  have  seen  that  Nasse  and  Moricke  incline  to  the  affirmative,  although 
they  admit  this  only  hypothetically.  Rumberg  goes  farther  and  says  that 
albuminuria  cannot  exist  without  a  kidney  lesion.     The  filtration  of  al- 


DISEASES   OF   PREGNANCY.  77 

bumin  is  only  explainable  b}^  some  modilication  in  the  permeability  of  the 
membranes,  and,  even  as  Kobert  has  shown  by  his  statistics  that  Bright's 
disease  is  much  more  common  in  ]oregnant  women  during  the  period  of 
sexual  activity,  Ollivier  arrives  at  the  same  results,  and  concludes  that 
i]i  a  good  many  cases  pregnancy  may  cause  or  hasten  Bright's  disease. 

"We  find,  then,  that  the  theory  of  renal  lesions  as  a  cause  of  albuminu- 
ria gravidarum,  a  theory  first  stated  by  Kayer  and  sustained  by  Gregory 
Christison,  Addison,  Johnson  in  England,  by  Imbert  Gourbeyre,  Cohen, 
Blot,  Cazeanx,  Devilliers,  Regnault,  Bach,Gubler,  Becquerel  and  Vernois, 
Lorrain,  Jaccoud,  Wieger,  and  modified  by  Peter  and  Petit  in  France, 
defended  also  by  Litzmann,  Frerichs,  Brilun,  Schottin  and  Rosenstein,  is 
generally  accepted. 

But  opinions  diif er  as  to  the  frequency  of  these  alterations.  While  Bailly 
admits  that  albuminuria  is  very  common,  particularly  in  the  acute  form, 
in  pregnant  women,  Blot,  Abeille,  Barker,  Briiiin,  Bamberger,  Hoff- 
meier,  Moricke,  Hypolitte,  recognize  the  renal  lesions,  but  consider  them 
much  less  common,  and  add  that  the  renal  lesions  may,  sometimes,  ante- 
date the  pregnancy,  and  at  other  times  depend  upon  other  causes  than 
those  of  pregnancy.  Bartels,  Spiegelberg  and  Schroeder  claim  that  the 
changes  in  the  kidney  during  pregnancy  are  analogous,  not  to  say  identi- 
cal, to  those  in  the  liver,  and  admit,  with  Dickinson,  that  the  kidney 
during  pregnancy  may  undergo  a  fatty  degeneration.  There  exists  a 
puerperal  kidney  as  well  as  a  cardiac  kidney,  the  first  being  more  dan- 
gerous than  the  secoiid. 

Olshausen  acknowledges  the  kidney  lesion,  but  the  primary  lesion  he 
considers  a  catarrh  of  the  bladder,  the  other  only  being  a  secondary  lesion. 
The  inflamm.ation  is  transmitted  to  the  uterus,  thence  to  the  kidneys 
secondarily. 

Cassin  has  revived  the  opinion  of  Bouchard,  and  refers  to  this  interest- 
ing fact:  "  When  albuminous  urine  is  boiled,  add  Tanret's  reagent,  or 
pici'ic  acid,  albumin  coagulates,  and  this  coagulation  may  take  place  in 
two  ways: 

"Either  the  urine  remains  opalescent  or  milky,  or  it  may  separate  out, 
and  the  albumin  presents  a  solid  mass  in  the  liquid  (this  mass  may  be 
solid  or  lumpy  or  as  fine  as  sand).  Each  of  these  conditions  has  a  distinct 
significance.  The  finely  coagulated  albumin  represents  a  transient  albu- 
minuria, such  as  one  observes  in  severe  fevers,  alcoholism.  The  retrac- 
tile coagnlum,  on  the  other  hand,  indicates  a  renal  lesion,  provided  we  are 
certain  that  the  urine  contains  neither  blood  nor  pus." 

Cassin,  in  47  albuminuric  women  in  labor,  has  found  in  31  cases  the 
urine  opalescent  in  appearance,  and  1 6  times  the  albumin  was  precipi- 
tated in  lumps.  In  the  31  cases,  the  albumin  disappeared  in  forty-eight 
hours;  of  the  16  cases,  in  six  the  albuminuria  was  slight,  in  ten  the  albu- 
minuria persisted,  in  seven  the  urine  contained  cells  and  a  great  number 


78 


A    TREATISE    ON    OBSTETRICS. 


of  granular  casts,  identical  to  those  "which  line  the  tubules.  In  the  ten 
in  which  the  albuminuria  was  retractile,  4  had  puerperal  complications. 
The  observations  were  taken  on  124  women: 


5  observations  during  the  7th  month  0  albuminuric 
45         "  "     ■         8th      "       5 


124 


9th 


1  in  15.5. 


The  figures  of  the  ninth  month  represent  the  total,  because  the  exami- 
nations of  the  previous  months  were  continued. 

Cassin,  taking  the  different  (ipinions  of  authorities,  shows  that  they 
may  be  reduced  to  three:  1st.  A  chemical  condition  of  the  blood.  2d. 
Change  in  pressure.  3d.  Conditions  of  the  histological  elements  of  the 
kidneys.  But  he  denies,  or  at  least  accepts  only  partially,  the  first  two 
theories,  and  accepts  the  idea  of  fatty  degeneration  of  the  kidney.  "It  is 
sufficient  to  realize  that  the  liver  and  kidney  are  organs  which  cooperate 
with  each  other,  in  order  to  infer  that  changes  which  pregnancy  produces 
in  the  latter  organ  would  take  an  important  part  in  the  pathology  of 
albuminuria." 

Hoffmeier,  who  believes  in  the  theory  of  the  kidney  lesions,  has  made  a 
careful  study  of  them,  and  found  in  5000  confinements  in  Schroeder's 
clinic,  from  September  1st,  1867,  to  April  1st,  1878,  137  cases  of  nephritis, 
of  which  104  were  complicated  by  eclampsia — 2  per  cent.  He  has  col- 
lected them  in  the  followinsr  table: 


1 

ob 

O 

73 

a) 
P 

CD  T3 
^    O 

-3  a 
^  o 

cw. 

0) 

s 
o 

< 

'3 
p 

o 

Nephritis  with  Eclampsia, 

33 

11 

22 

20 

15 

2 

2 

31 

Nephritis  alone,      .... 

104 

41 

63 

62 

46 

2 

89 

15 

Total,            .... 

137 

52 

85 

82 

61 

4 

91 

46 

From  this  table  we  see  that  nephritis  does  not  compromise  the  life  of 
mother  and  child  solely  on  account  of  the  possible  complication  of 
eclampsia,  but  that  the  form  in  which  it  presents  itself  ought  to  be  given 
serious  consideration. 

This  is,  besides,  the  opinion  of  Bartels,  who  says,  "  In  cases  in  which 
pregnancy,  confinement,  and  the  puerperal  state  pass  without  uraemic 
symptoms  being  developed,  rapid  recovery  generally  follows,  with  a  com- 
plete disappearance  of  the  renal  symptoms;  but,  as  Litzmann  adds,  the 
passage  into  a  chronic  state  is  more  frequent  than  in  other  forms  of  acute 
nephritis." 

Hoffmeier  has  often  noted  a  corresponding  alteration  of  the  liver,  and 
sees  in  this  proof  that  nephritis  depends  upon  an  over-activity  of  the  renal 


DISEASES    OF    PREGNANCY.  79 

function,  and  in  the  fact  that  albuminuria  is  met  often  in  twin  pregnan- 
cies.    In  13?  cases  of  nephritis,  there  were  9  cases  of  multiple  pregnancy. 

Nephritis  during  pregnancy  may  occur  in  two  forms;  acute  parenchy- 
matous— m  this  form  chiefly  do  we  have  eclampsia  (in  104  cases  given 
above,  in  89  renal  symptoms  declared  themselves  suddenly) — at  other  times 
a  chronic  form,  characterized  generally  by  a  diminution  of  urine  which 
may  go  on  to  complete  suppression.  The  urine  contains  a  considerable 
amount  of  albumin,  and  more  or  less  casts.  In  137  cases  cited  by  Hoff- 
meier,  46  presented  this  form,  of  which  31  had  simple  nephritis  and  15 
nephritis  with  eclampsia.  It  is  in  this  form,  as  Litzmann  and  Georgi  have 
shown,  that  one  sees  the  disease  develop  a  chronic  inflammation  of  the 
kidneys. 

lloffmeier  has  found  in  28  women,  discharged  living,  8  only  could  be 
considered  c}.ired,  5  were  unknown  and  15  were  discharged  still  having 
symptoms  of  the  disease. 

What  is  the  conclusion  to  be  drawn  from  all  these  theories  ?  On  which 
can  we  rely  ?  We  believe  it  is  impossible  to  adopt  one  exclusively,  and  it 
is  also  true  that  each  of  the  authorities  who  have  proposed  these  different 
theories  would  be  obliged  to  confess  that  they  could  not  explain  all  cases 
of  albuminuria  during  pregnancy  by  it  alone.  The  theory  which  attri- 
butes albuminuria  to  a  temporary  or  permanent  renal  lesion  seems  to  us 
most  rational,  and  yet  it  has  happened  to  us,  as  to  all  authors,  to  make 
autopsies  on  eclampsic  and  albuminuric  women,  and  never  to  have  found 
either  superficially  or  with  the  microscope  any  renal  lesion.  We  think 
that  Cassin  is  absolutely  correct  when  he  concludes  in  regard  to  these  dif- 
ferent theories  in  the  following  way:  "  Pregnancy  produces  a  condition 
favorable  to  the  passage  of  albumin  into  the  urine,  but  the  change  of 
the  blood,  by  pressure,  or  by  its  constitution,  the  influence  of  renal  stea- 
tosis, do  not  explain  it,  because  leucomuria  should  be  as  frequent  as  the 
gravid  state.  They  explain  only  the  tendency  to  albuminuria.  The  fire 
is  ready,  a  spark  is  wanted  to  light  it  up — then,  under  the  least  pathologi- 
cal influence,  the  renal  trouble  shows  itself  without  always  being  the  ex- 
pression of  the  same  lesion." 

Mohammed  and  Barnes  have  further  demonstrated  that  the  use  of  the 
sphygmograph  in  the  puerperal  state  would  give  us  warning  of  impending 
albuminuria,  and  its  frequent  consequence,  eclampsia.  ''  The  strong 
arterial  tension  which  exists  generally  in  the  latter  part  of  pregnancy  is 
most  marked  in  primiparse  and  constitutes  a  predisposition  to  albumin- 
uria and  eclampsia.  One  should  fear,  then,  these  two  accidents.  Where 
the  lying-in  period  is  normal,  this  high  tension  soon  disappears,  as  we 
can  prove  at  the  second  to  the  third  day,  in  the  tracing  which  corresponds 
to  the  milk  fever.  This  tracing  is  very  characteristic.  It  indicates  a  full 
pulse,  soft,  slightly  dicrotic,  beating  120,  and  is  simply  the  vascular  excita- 
bility following  the  secretion  of  milk.     It  is  analogous,  according  to  Mo- 


80  A    TREATISE    ON    OBSTETRICS. 

hammed,  to  the  condition  which  exists  in  man  during  a  state  of  alcohoHsm. 
Afterward  the  pulse  becomes  gradually  normal,  also  the  temperature 
(100°  to  101°)  which  accompanies  this  strong  tension  pulse.  If  it  persists, 
it  indicates  some  unfavorable  complication  which  may  predispose  to  al- 
buminuria, i.e.,  a  chill,  which  increases  tension  in  the  kidneys,  constipa- 
tion, which  poisons  the  blood,  unless  indeed  this  increased  arterial  tension 
is  not  due  to  nervous  excitability,  which  alone  may  suffice  to  cause  it,  as 
the  author  observed  in  a  case  after  the  use  of  chloroform  and  forceps." 
(Hypolitte.) 

We  cannot  accept  this  comparison  of  Barnes,  milk  fever  being, 
in  our  opinion,  very  rare,  and  its  physiological  appearance,  as  is 
seen  from  study  and  observation,  and  the  thesis  of  Ohantreuil,  is  accom- 
panied by  a  pulse  of  about  100  to  104  and  a  temperature  of  about  98.3°. 
Should  the  pulse  and  temperature  pass  these  limits,  the  puerperal  period 
is  no  longer  physiological  but  pathological,  the  woman  is  sick,  and,  if  the 
high  tension  pulse  exists  as  a  prodroma  of  albuminuria  (as  it  may,  we 
admit,  according  to  Mohammed  and  Barnes),  it  may  also  be  met  with  in 
other  conditions,  particularly  in  any  of  the  accidents  which  complicate  a 
physiological  lying-in  period,  and  endanger  seriously  the  woman's  life. 

Summing  up  the  causes  of  albuminuria  in  pregnant  women,  we  can 
say  with  Dumas: 

1st.  Pregnancy  is  a  predisposing  cause  of  albuminuria:  a.  By 
the  age  at  which  it  occurs;  b.  The  disturbances  in  the  stomach, 
lungs  and  nervous  system  which  accompany  it;  c.  The  modifications  in 
the  quality  and  quantity  of  the  blood  which  are  the  result;  d.  The  nature 
of  the  albuminoid  material  introduced  into  the  circulation;  e.  The  con- 
gestion of  certain  organs  which  this  state  of  blood  induces.  Women  are, 
during  pregnancy,  predisposed  to  albuminuria. 

2d.  Pregnancy  is  an  efficient  cause  of  albuminuria,  a.  luprimiparse;  5. 
By  the  functional  relations  which  exist  between  the  uterus  and  the  kid- 
neys; c.  By  the  increase  of  urinary  secretion;  d.  By  the  mechanical 
pressure  of  the  uterus,  (in  primiparse,  twin  pregnancies,  retroversion,  hy- 
dramnios,  rachitis;  c.  By  morbid  conditions  which  may  accompany  it  and 
to  which  it  may  always  give  a  serious  aspect  (pernicious  anaemia,  diseases 
of  the  heart). 

3d.  Pregnancy  may  act  at  the  same  time  as  a  predisposing  and  exciting 
cause,  whenever  there  exists  one  of  the  occasional  causes  wliich  we  have 
enumerated.     Hence: 

a.  Albuminuria  dependent  upon  changes  in  the  blood,  (albuminuria 
in  the  early  part  of  pregnancy,  albuminuria  or  dyscrasia  of  pregnancy). 

h.  Albuminuria  dependent  upon  anatomical  and  functional  changes 
of  the  kidneys  (organic  albuminuria  of  pregnancy). 

c.   Accidental  albuminuria  of  j)regnancy. 

a.  Mechanical  albuminuria  of  pregnancy  (albuminuria  in  the  last 
months  of  pregnancy). 


DISEASES    OF   PREGNANCY.  81 

Symptoms. — The  first  and  only  vulid  one  is  the  presence  of  albumin  in 
the  urine.  There  arc  two  methods  for  analysis,  heat  and  nitric  acid;  but 
if  one  wishes  to  be  more  exact,  he  must  adopt  the  method  of  Petit  or 
Hitter.  [The  descriptions  of  these  methods  are  omitted,  and  our 
readers  are  referred  to  works  on  medical  chemistry  for  methods  of  estima- 
ting the  amount  of  albumin  in  the  urine. — Ed.] 

Other  symptoms  are  the  general  condition  of  the  patient,  who  is  chlorotic 
or  anaemic,  with  various  digestive  disturbances,  and  becomes  gradually 
pale  and  feeble.  Next,  oedema  appears;  first  in  the  lower  extremities, 
slowly  becomes  general,  and  invades  the  face,  so  that  the  patient  presents 
a  characteristic  appearance. 

CEdema  remains  permanent  in  these  localities,  but  it  may  vary  in  its 
amount,  and  even  collect  in  the  serous  cavities,  and  there  may  be  general 
anasarca.  But  puffiness  about  the  face  is  never  absent.  The  pulse, 
small,  hard,  thready,  quick,  is,  in  some  cases,  particularly  when  eclamp- 
sia is  imminent,  almost  imperceptible.  Finally,  there  may  be  hemor- 
rhages, epistaxis,  heematuria.  Thirst  is  excessive,  digestive  disturbances 
are  very  pronounced,  and  may  be  accompanied  by  pain  in  the  epigastric 
region,  and  alternately  obstinate  constipation  or  a  persistent  diarrhoea. 
jSText  the  respiratory  functions  are  more  or  less  disturbed,  there  is  dyspnoea, 
cough,  and  lastly  neuralgic  pains  appear,  cephalalgia,  indistinct  vision  even 
to  blindness,  stupidity  and  deafness.  These  last  symptoms  generally  an- 
nounce eclampsia,  but  they  are  often  slightly  pronounced,  and  albumin- 
uria may  pass  unperceived  if  the  urine  is  not  carefully  examined. 

This  is,  indeed,  a  precaution  that  should  be  taken  in  all  pregnant 
women,  particularly  primiparee.  The  examination  should  be  repeated  at 
intervals,  above  all  at  the  end  of  pregnancy,  for  at  this  time  albuminuria 
is  most  likely  to  show  itself,  although  it  sometimes  appears  earlier. 
Prestat  reports  cases  in  second  month.  Bach  in  sixth  week,  Cazeaux  at 
four  months,  Cohen  and  Peter  at  five  months.  As  a  general  rule  it  ap- 
pears sooner  in  primiparse  than  in  multiparas.  Another  reason  for  exam- 
ining the  urine  at  frequent  intervals,  is  that  the  quantity  of  albumin 
which  may  be  found  is  variable,  not  only  from  one  day  to  another,  but  from 
morning  to  evening.  Albuminuria  may  disappear  completely  for  a  time 
to  reappear  again  in  greater  quantity.  Its  duration  may  be  very  tran- 
sient, sometimes  only  for  a  few  days  or  hours  but  more  often  for  five  or 
six  weeks,  increasing  up  to  the  time  of  confinement,  to  disappear  entirely 
in  three  or  four  weeks  after  labor.  This  is  not  always  the  case,  and  we 
have  seen  it  once  persist  after,  confinement.  Tarnier  has  seen  it  last  fif- 
teen months. 

We  confined,  six  months  ago,  a  patient  in  whom  albuminuria  still  jDer- 
sists.  Finally,  albuminuria  alone  may  kill  the  patient,  as  observations 
show. 

Vol.  II —6. 


82  A   TEEATISE   ON   OBSTETRICS. 

The  greater  tlie  albuminuria,  the  more  quickly  will  pregnancy  be  in- 
terrupted. 

In  the  twenty-eight  cases  cited  above  from  Hoffmeier,  only  ten  went 
to  full  term.  In  eight  of  these  the  pregnancy  was  interrupted  in  the  ninth 
month  (the  G-ermans  count  pregnancy  by  the  ten  lunar  months),  and  in 
nine  at  a  time  when  the  foetus  was  not  viable;  and  of  eighteen  women 
who  died,  five  went  to  the  end  of  their  pregnancy;  in  five  pregnancy  was 
interrupted  in  the  ninth,  or  from  the  ninth  to  the  tenth  month;  three 
before  the  beginning  of  the  ninth  month. 

Of  forty-five  cases  of  pregnancy  with  nephritis:  pregnancies  going  to 
term,  fifteen;  premature  confinements,  thirteen;  abortions,  seventeen. 

Albuminueia  op  Labor. 

Under  this  name,  we  understand  not  only  albuminuria  recognized  dur- 
ing labor,  but,  according  to  Hypolitte,  Peter,  Dumas,  Cassin,  albuminuria 
of  the  two  or  three  days  which  immediately  precede  labor.  It  appears 
essentially  dependent  on  this  act,  begins  and  ends  with  it,  and  its  duration 
and  intensity  are  often  proportionate  to  the  duration  of  labor.  Petit  has 
shown  that  if  Peter's  theory  can  fully  explain  all  the  particulars  of  album- 
inuria of  pregnancy,  it  is  not  so  in  albuminuria  of  labor,  and,  whilst  adopt- 
ing in  great  part  the  ideas  of  his  teacher,  he  thus  modifies  Peter's  theory: 

"^  priori  one  would  think  that  expulsive  efforts  alone  are  capable  of 
congesting  the  kidney  enough  to  cause  filtration  of  the  urine,  but  if  we 
consider  what  takes  place  in  the  part  of  the  abdominal  circulation  during 
dilatation,  we  will  easily  realize  that  this  organ  must  undergo,  at  the 
same  time  with  each  uterine  contraction,  a  certain  degree  of  hypersemia, 
capable  also,  although  in  a  less  degree,  of  producing  the  same  result. 
The  uterine  vessels,  arteries  and  veins,  acquire  an  extreme  development 
during  pregnancy;  the  uterine  circulation  is  interrupted  more  or  less  com- 
pletely in  the  uterine  walls  during  a  uterine  contraction.  The  enormous 
quantity  of  blood  brought  continuously  by  the  utero-ovarian  arteries  ceases 
at  each  uterine  pain,  to  find  a  free  flow  through  the  uterus.  There  results 
then,  by  a  mechanism  somewhat  analogous  to  that  of  the  hydraulic  ram, 
an  increased  pressure  in  the  portion  of  these  arteries  which  remain  perme- 
able and  also  in  the  trunks  from  which  they  spring. 

"The  utero-ovarian  arteries  arise  from  the  antero-lateral  part  of  the  ab- 
dominal aorta,  a  short  distance  from  the  origin  "of  the  renal  arteries,  and 
at  times  they  arise  from  the  renal  arteries  themselves.  It  is  then  in  the  lat- 
ter, as  well  as  in  the  kidney,  that  this  increased  pressure  is  felt  soonest  and 
strongest.  But  while  it  shuts  off  the  passage  of  arterial  blood  toward  the 
uterus,  each  uterine  contraction  presses  out  in  some  way  the  engorged 
uterine  blood,  and  accelerates  the  return  utero-ovarian  circulation:  again, 
the  abnormal  distension  of  the  trunks  to  which  these  veins  lead,  i.e.,  the 
part  of  the  inferior  vena  cava,  near  the  opening  of  the  emulgent  veins, 


DISEASES    OF   PKEGlSrANCY. 


83 


or  some  of  the  emulgent  veins  themselves,  hinders  the  course  of  the  blood 
which  returns  to  the  kidneys;  and  venous  stasis  in  the  organs  results,  i.e., 
a  condition  favorable  to  the  production  of  albuminuria.  If  these  views 
are  correct,  uterine  contraction  exerts  a  pressure  toward  the  kidney  from 
two  sides  at  once:  through  the  arteries  by  increasing  arterial  tension, 
tlirough  the  veins,  by  increasing  venous  pressure;  and  we  perceive  how 
this  arterial  tension,  persisting  for  a  long  time,  determines  the  passage  of 
albumin  into  the  urine;  above  all  if  we  admit  with  Peter  that  there  exists 
physiologically,  by  the  fact  of  pregnancy  alone,  a  functional  hyperasmia  of 
the  kidney. 

Finally,  Peter  believes  that  the  abdominal  muscles  have  a  part  in  this 
pressure.  As  to  the  notable  increase  in  the  albumin  which  he  has  de- 
monstrated in  the  first  urine  passed  after  the  birth  of  the  foetus.  Petit 
explains  this  by  the  fact  that,  "  accustomed  to  work  during  pregnancy, 
under  a  gradually  increasing  pressure,  of  which  they  are  suddenly  de- 
prived, the  kifineys  find  themselves  exposed  to  an  intense  congestion.'" 

Frequency . — Albuminuria  of  labor  is  much  more  frequent  than  that  of 
pregnancy,  and  it  has  been  met  with  by  Blot  lin  5;  Petit  1  in  4.8; 
Hypolitte  1  in  4.23;  Litzmann  40.78  per  cent.  Moricke  37.  per  cent. 

Age  and  primiparity  play  an  important  part:  thus  Cassin  has  found,  in 
427  cases,  197  primiparse,  67  or  34  per  cent;  250  multiparas,  42  or  16 
per  cent. 

Number  of  Pregnancies. 
parse, 


143 

II. 

66 

III. 

12 

IV. 

13 

V. 

4 

VI. 

7 

VII. 

5  having  had  more  than  7  children. 

Age. 

9  less  than  18  years, 
142  from  18  to  24  years, 
37     "     24  "  30     '' 
7  more  than  30     " 

The  difference  of  the  length  of  labor  is  very  marked;  less,  however, 
than  would  be  supposed.     Thus,  according  to  Cassin: 

Av.  length  of  labor. 

Primiparse,  albuminuric,  31;  vertex  presentation  L.O.A.  Vl\  hours. 

non-albuminuric,         .         .         .  ''  12         ^^ 


25  = 

lin 

5.68 

9  = 

1  '' 

7.3 

3  = 

1  '' 

4 

1  = 

1  " 

13 

0 

2  = 

1  " 

3.5 

2  = 

1  '' 

2.5 

5  = 

1  in 

1.8 

43  = 

1  '^ 

3.3 

15  = 

1  '' 

2.4 

4  = 

1  " 

1.6 

albuminuric, 
non-albuminuric, 
Multiparae,  albuminuric,  31  . 
non-albuminuric, 
albuminuric, 
non-albuminuric, 


E.O.P.  12 

16  to  17 
L.O.A.  9i 

R.O.P.  18i 

9 


84  A   TREATISE    ON    OBSTETRICS. 

In  our  opinion  this  table  is  not  of  great  value,  because  it  is  in  positive 
contradiction  to  facts  daily  observed. 

Presentations  in  E.  0.  P.  would  give,  if  one  refers  to  the  tables  of  Cassin, 
a  duration  of  labor  much  greater  in  multiparEe  than  in  primiparas,  but 
the  contrary  is  true.  Indeed,  intervention  is  more  frequent  inprimiparse 
than  in  multipara?;  but  even  taking  into  account  this  intervention,  the 
duration  of  labor  is  not  comparable  in  the  two  cases.  It  is  the  same  of 
dystocia,  of  which  Cassin  does  not  describe  the  nature. 

In  338  women  not  albuminuric,  there  were  12  cases  of  dystocia,  or  3.5 
per  cent. 

In  109  women  albuminuric,  there  were  18  cases  of  dystocia  or  16.5  per 
cent.  Albuminuria,  in  turn,predisposes  to  hemorrhage.   Thus,  fromCazin: 

In  338  women  not  albuminuric,  there  were  26  cases  of  hemorrhage. 

In  109  women  albuminuric,  there  were  23  cases  of  hemorrhage. 

We  note  finally,  according  to  Eayer,  Blot,  Imbert  Groubeyre,  Molas, 
etc.,  that  these  hemorrhages,  generally  uterine,  manifest  themselves  par- 
ticularly at  the  time  of  delivery,  and  may  be  met  with  in  other  organs, 
the  liver,  brain,  lungs  and  bladder. 

Although  we  have  insisted  at  length  on  the 'frequency  of  oedema  and 
dropsy,  it  is  not  to  be  believed  that  there  is  a  constant  and  absolute  rela- 
tion between  oedema  and  albuminuria;  because,  on  the  one  hand,  it  may 
be  absolutely  absent,  when  women  are  albuminuric,  according  to  the  re- 
searches of  Blot,  and  the  cases  we  have  cited  in  our  thesis  of  1872,  and, 
on  the  other  hand,  oedema  exists  often  in  pregnant  women,  without  a 
trace  of  albumin  in  the  urine,  and  this  fact  has  been  demonstrated  with- 
out a  doubt  by  Devilliers  and  Eegnault. 

The  last  point  to  be  noted  is  the  relation  which  exists  between  albu- 
minuria and  eclampsia,  and,  without  encroaching  on  the  following  chapters, 
which  are  devoted  to  eclampsia,  there  is  a  statement  one  can  make  almost 
absolutely, — we  say  almost,  because  there  are  some  exceptions.  This  is 
the  statement:  "  If  all  albuminuric  cases  are  not  eclampsic,  all  eclampsic 
patients  are  albuminuric." 

Peter  does  not  admit  this.    It  follows,  however,  from  these  statistics: 


Albu. 

Non-albu. 

Lever,                  in    14  cases 
Brummerstadt,   "135     " 
Miezkowski,        "     50     " 
Sfcaude,                "     40     " 
Macdonald,         "      9     " 

of  eclampsia, 

a             a 
a            a 

a             a 

.       13 
.     106 
.       46 
.       32 

8 

1 

29 
4 
8 
1 

Depaul  has  met  in  his  private  practice  ana  in  that  of  his  colleagues,  by 
whom  he  was  called  in  consultation,  twenty  cases  where  he  did  not  find 
albumin,  and  we  can  add  cases  of  Trousseau,  Leuret,  P.  Dubois,  Imbert 
Goubeyre,  Mascarel,  L'huillier,  Schroeder,  Trelat,  Spiegelberg,  Davis, 
Hartmann,  Hicks,  Osborn,  Van  du  Meersch,  Dohrn,  Fabre,  etc. 


Labors. 

Eclampsia. 

No  albuminuria. 

30,283 

133 

4  only. 

54 

2     " 

DISEASES    OF    PREGISrANCY.  .  85 

These  cases,  altliougli  exceptional,  tend  to  increase,  and  they  justify  our 
assertion.  The  frequency  of  the  occurrence  of  eclampsia  and  albuminuria 
has  been  noted  by  all  authors:  Blot  ni  41,  albuminuric  7  times;  Stoltz  in 
7,  1;  Devilliers  in  20,  11;  Mayer  in  63,  7;  Litzmann  in  13,  5;  Braun  in  35, 
6;  Inibert  Goubeyre  in  159,  94;  Hubert  du  Louvain  in  135,  36;  Eosen- 
stein  in  40,  10;  Hoffmeier  in  30,  10;  Macdonald  in  5,  5. 

The  two  tables  reported  in  our  thesis  were  furnished  us  by  : 

Clinic,  .... 
Maternity,    . 

As  albuminuria,  so  eclampsia  is  more  frequent  during  labor  than 
during  pregnancy,  and  there  is  here  also  a  direct  relation  between  eclamp- 
sia and  albuminuria.  Eclampsia  in  some  cases  may  appear  early,  most  fre- 
quently, however,  during  the  seventh  or  ninth  month,  above  all  during 
the  few  days  or  hours  which  precede  labor,  but  it  may  come  also  after 
labor — thus: 


Jacquemier, 
Jaccond,     . 
Braiin, 
Wieger, 
Scanzoni,    . 
Pajot, 

Diagnosis. — This  depends  on  two  conditions:  1st.  To  establish  the  fact 
of  albuminuria.  The  examination  of  the  urine  leaves  no  doubt;  2d.  To 
find  out  whether  the  albuminuria  is  dependent  upon  pregnancy,  or  upon 
other  causes.  Here  the  sign  given  by  Bouchard  and  Cassin  may  be  of 
great  importance,  coagulation  of  albumin  indicating,  according  to  them, 
a  renal  lesion;  the  non-retractile  coagulum  indicates  a  transient  albumi- 
nuria, such  as  we  observe  in  severe  forms  of  alcoholism,  etc.  The  im- 
portance of  this  sign  is  understood  (if  further  observations  confirm  it)  not 
only  from  a  diagnostic,  but  also  from  a  prognostic  standpoint. 

Prognosis. — The  disease  may  be  always  considered  grave,  because,  if  a 
number  of  women  are  cured,  there  are  a  great  many  who  die,  either  from 
the  disease  itself  or  from  the  complications,  and  we  have  seen  how  the 
albuminuria  of  pregnancy  can  become  the  starting  point  of  a  chronic 
aephritis. 

The  prognosis  will  vary  according  to  the  nature,  the  duration,  more  or 
less  long,  of  urinary  troubles,  their  intensitj^,  the  existence  or  not  of  kid- 
ney lesions  and  the  morbid  cause,  the  severity  of  the  complications. 

The  prognosis  is  particularly  grave  when  the  albuminuria  exists  pre- 
vious to  pregnancy,  although  we  make  an  exception  in  case  of  albumin- 


Cases. 

During- 

During- 

After 

Pregnancy. 

Labor. 

Labor 

.     197 

53 

59 

85 

.       47 

18 

20 

8 

.       44 

12 

21 

11 

.     455 

109 

235 

111 

.       28 

2 

23 

3 

.     200 

60 

100 

40 

86  •  A   TEEATISE    ON    OBSTETRICS. 

iiria  of  labor  and  of  eclampsia.  Hoffmeier,  in  48  cases  of  chronic 
nephritis,  has  noted  death  18  times.  In  104  cases  of  eclampsia  death  has 
resulted  in  39  per  cent.;  Rosenstein  32.9  per  cent.;  Devilliers  in  11  out 
of  20  cases. 

Albuminuria  is  no  less  fatal  to  the  foetus  than  to  the  mother,  and  even 
excluding  eclampsia,  which  has  an  extremely  bad  prognosis  for  the  child, 
albuminuria  is  none  the  less  one  of  the  causes  which  threatens  seriously 
the  life  of  the  child.  On  the  one  hand,  indeed,  it  may  die  from  the  dis- 
ease itself,  and  again,  albuminuria  being  a  frequent  cause  of  abortion  and 
premature  labor,  it  compromises  certainly  the  life  of  the  child,  or  subjects 
it  to  all  those  untoward  circumstances  in  which  the  child  finds  itself  when 
born  before  term. 

Blot  reports  6  cases  of  premature  labor.  Eayer,  Barker,  Hubert  de 
Louvain  admit  the  frequency  of  abortion  and  premature  labor.  The 
same  is  true  of  Braiin,  80  per  cent,  Hoifmeier  in  45  cases  of  nephritis 
has  only  seen  15  cases  go  to  term,  13  premature  labors,  17  abortions;  and 
in  33  cases  of  simple  nephritis,  20  children  died,  13  lived;  in  104  cases 
of  nephritis  with  eclampsia  62  children  died,  46  lived,  i.e.,  in  a  total  of 
137  cases,  82  children  died,  61  lived. 

Finally,  albuminuria,  aside  from  post-partum  hemorrhage,  predisposes 
the  patient  to  puerperal  complications,  (peritonitis,  septicaemia,  puerperal 
mania,  etc.,)  and  we  readily  see  the  importance  of  treatment. 

Treatment. — Considering  the  number  of  causes  of  albuminuria  and  the 
■  different  theories  which  have  been  given  to  it,  one  can  understand,  as 
Grueneau  de  Mussy  has  said,  how  absurd  it  would  be  to  seek  for  a  uni- 
form treatment  for  albuminuria;  but  it  is  not  at  all  the  same  of  the  al- 
buminuria of  pregnancy.  This,  indeed,  presents  peculiar  characteristics, 
by  the  fact  that  it  is  intimately  dependent  upon  pregnancy,  by  its  fre- 
quent relation  to  eclampsia,  by  the  influence  which  it  exercises  on  the 
child;  by  those  circumstances,  in  a  word,  under  which  it  is  produced. 
The  increase  in  the  quantity  of  blood,  the  alterations  in  the  pregnant 
woman,  the  changes  which  take  place  in  the  circulation,  the  particular 
tendency  to  congestion  which  the  woman  presents  during  gestation,  seem, 
a  priori,  to  indicate  the  direction  this  treatment  should  take. 

Diminish,  combat,  suppress,  if  you  can,  this  tendency  to  renal  conges- 
tion, bring  the  blood  into  its  normal  condition;  these  are  the  two  great 
indications  which  should  govern  our  treatment  of  albuminuria  gravidarum. 

Venesection  fills  better  than  any  other  treatment  the  first  indication, 
and  here  we  agree  with  Peter,  our  teacher  and  friend.  We  cannot  go  as 
far  as  he  does,  in  admitting  that  the  greater  frequency  of  complications, 
and  of  eclampsia,  in  the  last  thirty  years,  depends  on  the  fact  that  vene- 
section in  pregnant  women  has  been  lost  sight  of.  But  it  cannot  be  de- 
nied that  venesection,  in  a  great  many  cases,  renders  wonderful  service,  say 
4500  grains,  and,  as  we  have  already  said,  we  have  seen  Beau  derive  excel- 


DISEASES    OF    PREGISTATSrCY.  87 

lent  results  from  it.  Wo  prefer  general  blood-letting  to  local  (leeches, 
cupping,)  which  do  not  appear  to  us  without  inconveniences,  in  oedemat- 
ous  and  greatly  swollen  women.  Should  we  make  use  of  it  in  every  case  ? 
No,  for  if  bleeding  has  its  advantages,  it  also  has  its  disadvantages,  and 
it  may,  in  certain  women,  even  when  it  is  moderate,  cause  a  feeble  state 
which  cannot  be  without  danger  to  mother  and  child.  Venesection,  in- 
deed, withdraws  blood-globules  from  the  pregnant  woman  who  has  less 
than  the  normal  amount.  Finally,  there  are  cases  where  it  is  impossible 
to  use  it.  We  have  at  this  moment  a  case  in  mind.  The  woman  in  ques- 
tion is  pregnant  for  the  fourth  time,  and,  beside  a  slight  amount  of  albu- 
min, has  hemorrhages,  dependent,  probably,  on  a  faulty  insertion  of  the 
placenta. 

The  patient  has  been  pregnant  for  eight  and  one-half  months,  and  has 
already  had,  at  intervals  of  forty-eight  hours,  two  hemorrhages,  slight  it 
is  true,  but  dependent  upon  placenta  prtevia.  In  presence  of  the  possibil- 
ity of  a  future  severe  hemorrhage,  we  do  not  dare  to  weaken  the  patient 
by  blood-letting,  inasmuch  as  these  two  spontaneous  hemorrhages  have 
not  led  to  any  amelioration  of  the  condition  of  the  patient. 

Further,  before  bleeding,  we  should  always  make  use  of  purgatives,  in 
a  repeated  and  constant  manner.  We  try  to  obtain,  by  means  of  purga- 
tives, a  serous  intestinal  discbarge,  which  withdraws  from  the  woman  a 
larger  quantity  of  serum,  leaving  behind  the  blood- globules,  and  therefore 
we  prefer  the  saline  purgatives,  sulphate  of  soda,  sulpho-vinate  of  soda, 
Seidlitz  powders,  Carlsbad  salts,  mineral  purgatives,  Seidlitz,  BirminstoU, 
Pullna,  Hunyadi  Janos,  and  they  are  employed  by  us  every  day  in  doses  of 
a  glass,  or  at  least  every  other  day;  in  a  word,  we  try  to  produce  a  revul- 
sive effect  on  the  intestine.  But,  in  turn,  we  discard  all  revulsives  ap- 
plied to  the  skin,  in  particular  sinapisms  and  blisters;  for  several  times 
we  have  seen  gangrenous  patches  produced  where  they  had  been  applied, 
and  this  should  not  surprise  us  when  we  consider  the  changes  of  nutri' 
tion  in  the  cedematous,  infiltrated,  and  distended  tissue. 

We  try,  further,  in  all  our  pregnant  women,  to  build  up  the  constitution, 
by  tonics,  iron,  quinine,  wine,  etc.  But  we  have  little  faith  in  the  action 
of  these  agents  in  albuminuria,  and  they  are  excluded  by  the  treatment 
which  we  will  recommend  shortly. 

It  is  the  same  with  diuretics,  which  to  us,  as  to  Jaccoud,  appear  per- 
haps more  huriful  than  useful;  with  diaphoretics  which  are  inefficient. 
As  for  tannin  and  iodide  of  potash,  they  are  simply  adjuvants,  and  it  is 
the  following  treatment,  in  our  opinion,  that  it  is  best  to  use,  for  it  is  by 
far  superior  to  all  others.  This  is  the  milk  diet  recommended  by  Tar- 
nier: 

''  1st  day,  a  quart  of  milk  with  two  portions  of  food. 

"  2d  day,  two  quarts    "       "      one  portion    "      '' 

*' 3d  day,  three    "       "       "  i       "  "      " 


88  A    TREATISE    OX    OBSTETRICS. 

'■4th.  day.  and  following  days,  four  quarts  of  milk,  or  milk  ad  libitum 
witliout  other  food,  without  other  drink. 

'"'  In  the  severe  cases,  if  prodromata  of  eclampsia  appear,  put  the  patient 
at  once  on  three  or  four  quarts  of  milk  per  day. 

"  The  influence  of  the  milk  diet  is  never  slow  in  manifesting  itself,  and 
in  eight  or  fifteen  days  after  the  commencement  of  the  treatment,  the  al- 
buminuria is  diminish.ed  very  considerably  or  even  cured.*' 

More  radical  than  Tarnier,  we  put  the  patient  at  once,  and  in  all  cases, 
on  a  milk  diet,  without  limiting  the  dose  which  she  ought  to  take,  and 
prohibit  immediately  all  other  kinds  of  food  or  drink. 

To  accustom  the  patient  gradually  to  a  milk  diet,  (which  ought  to  be 
taken  pure,  not  boiled,  no  sugar,  but  warm  or  cold  as  desired — we  pre- 
fer it  cold),  the  first  day  they  may  take  a  coifee-cupful  every  half  hour  or 
three  quarters  of  an  hour  or  more.  The  coffee-cup  is  replaced  the  next 
day  or  the  day  after  by  a  tea- cup,  and  when  the  patient  becomes  accustom- 
ed to  milk,  she  may  take  it  in  bowls-full,  day  or  night,  when  she  feels  in- 
clined. 

Since  we  have  emj)loyed  this  treatment,  we  have  seen  eleven  cases  of 
albuminuria  more  or  less  grave;  in  ten  cases  we  have  seen  it  entirely  suc- 
cessful. Albuminuria,  if  it  has  not  entirely  disappeared,  at  least  dimin- 
ishes in  enormous  proportions,  and  in  ten  cases  the  women  have  gone  to 
term  and  been  confined,  without  eclampsia,  of  living  children.  Twice  only 
have  we  failed;  in  one  case  the  woman  was  syphilitic,  and  the  albumin- 
uria had  persisted  six  months  after  the  confinement.  There  was  no 
eclampsia.  The  woman  was  delivered  at  seven  months  of  a  dead  child,  hav- 
ing in  it  and  on  its  placenta  syphilitic  lesions. 

In  the  other  case  the  milk  diet  completely  failed.  It  is  true  that  the 
patient  bore  it  badly,  it  was  not  taken  continuously,  and  consequently 
the  method  was  imperfectly  used.  But  for  successful  treatment,  it  is 
necessary  that  it  should  be  administered  for  a  certain  time,  that  it  should 
be  done  in  a  rigorous  and  exclusive  manner,  and  that  it  should  be  com- 
menced as  early  as  possible. 

But  this  is  not  always  possible,  and  one  meets,  unfortunately,  in 
certain  cases  an  irresistible  repugnance.  We  have  seen  such  a  case  in 
consultation,  and  were  obliged  to  resort  to  venesection,  and  to  purgatives. 
The  woman  was  seized,  nevertheless,  with  eclampsia,  which  was  cured  by 
chloroform  and  chloral.  One  need  not  fear  to  continue  the  milk  diet  for 
a  long  time,  even  after  the  disappearance  of  the  albuminuria,  for  this 
disappearance  may  be  momentary.  Besides,  the  patient  once  accustomed 
to  the  diet,  it  is  well  borne,  and  we  have  continued  it  for  three  months  in 
the  case  of  one  of  our  patients,  who  was  delivered  at  term,  without 
eclampsia,  of  a  well  nourished  child.  The  albuminuria  only  disappeared 
eight  days  after  confinement. 

There  remains  the  question  of  the  artificial  interruption  of  pregnancy. 


DISEASES    OF    PREGlNTAlSrCY.  89 

This  question  was  raised  for  the  first  time  by  Tarnier,  in  case  of  al- 
buminuria gravidarum;,  in  the  notes  which  he  added  to  the  treatise  of 
Cazeaux. 

"  All  accoucheurs/'  says  Tarnier,  "  are  agreed  that  labor  is  a  favorable 
circumstance  in  eclampsia.     We  might  ask  them  if,  to  arrest  albuminuria 
of  pregnancy,  and  to  prevent  possible  convulsions,  one  ought  not  to  con- 
sider the  induction  of  premature  labor.     This  question  has  generally  been 
answered  in  the  negative.     Indeed,  observations  are  not  wanting  to  de- 
monstrate that  after  suitable  treatment,  above  all  after  the  use  of  vene- 
section, the  albuminuria  may  diminish,  that  eclampsia,  even  after  having 
appeared,  may  disappear,  and  it  is  not  rare  to  see  under  these  circum- 
stances, the  pregnancy  continue  its  course,  and  terminate  in  a  normal 
confinement.    These  observations,  together  with  the  fact  that  the  women 
with  marked  albuminuria  do  not  necessarily  have    eclampsia,  indicate, 
that  one  ought  only  to  consider  the  question  of  premature  labor  as  pre- 
ventive treatment  in  eclampsia  with  great  caution.      We  believe,  how- 
ever, that  the  induction  of  premature  labor  may,  in  exceptional  cases, 
render  some  service.     Suppose,  at  the  outset,  a  woman    eight  months 
pregnant,  albuminuric,  threatened  with  eclampsia,  in  whom  labor  com- 
mences prematurely  and  spontaneously;  certainly  this  last  circumstance 
would  appear  to  the  majority  of    accoucheurs  favorable,    and  nothing 
would  be  tried  to  stop  the  labor.     Admit  this,  and  one  will  be  very  near 
accepting  the  induction  of  premature  la])or.     One  must  not  believe,  on 
the  other  hand,  that  eclampsia  awaits  the  appearance  of  labor  to  declare 
itself,  and  that  complications  will  arise  at  the  same  time  with  labor. 
Often,  on  the  contrary,  eclampsia  appears  before  the  end  of  pregnancy, 
labor  only  coming  on  afterward;   here  the  prognosis  is  still  less  grave,  as 
the  labor  is  more  advanced.     For  all  these  reasons,  we  believe  that  we 
should  not  discard  absolutely  the  induction  of  premature  labor,  but  in  or- 
der that  we  may  feel  authorized  to  propose  this  operation,  we  should  re- 
quire that  the  following  conditions  should  coexist: 

'■'1.  That  pregnancy  has  reached  the  end  of  the  eighth  month,  in  order 
that  the  new-born  child  can  be  raised  without  too  great  risk  or  difficulty. 

'•'2.  That  the  albuminuria  should  have  reached  a  certain  degree,  or  that 
the  patient  should  suffer  from  some  prodromata  of  eclampsia. 

"  3.  That  the  woman  should  be  a  primipara,  or  that  she  should  have 
suffered  from  eclampsia  in  a  previous  pregnancy. 

•''  4.  That  the  medical  treatment  has  proved  inefficient, particularly  vene- 
section. 

"  Under  these  conditions,  the  induction  of  premature  labor  seems  to  me 
rational,  and  I  am  disposed  to  adopt  it,  unless  further  facts  give  a  decided 
contradiction  to  my  present  way  of  thinking.'' 

We  do  not  know  whether  Tarnier  would  still  persist  in  these  views 
since  he  has  adopted  a  milk  diet  and  such  wonderful  results  have  been 


90  A   TREATISE    ON    OBSTETEICS. 

obtained  from  it;  but  tliey  have  been  accepted  by  Moricke,  who  goes  fur- 
ther than  Tarnier,  and,  considering  all  treatment  as  useless,  strongly  ad- 
vises the  induction  of  premature  labor;  also  Schroeder,  who  admits  the 
induction  of  labor;  and  Eichardson,  who  wishes  that  all  treatment  should 
be  first  tried,  and  when  nothing  diminishes  the  quantity  of  albumin,  and 
when  the  quantity  of  urine  becomes  less  and  less  marked,  that  the  induc- 
tion of  premature  labor  should  be  practised;  Lohlein,  Odebrecht,  Martin, 
who  wait  for  some  evidence  of  eclampsia. 

We  are  opposed  to  Tarnier,  and  these  other  authorities,  and  we  discard 
the  question  of  premature  labor  for  the  following  reasons: 

1.  The  success  which  we  have  had  with  the  milk  diet  is  such  that  we 
believe  all  other  treatment  useless,  particularly  when  the  milk  diet  is  care- 
fully and  sufficiently  observed  during  pregnancy,  and  soon  enough  to 
jDroduce  its  effects. 

2.  When  the  albuminuria  is  slight,  the  interruption  of  pregnancy  ap- 
pears useless,  the  gravity  of  the  accidents  which  occur  in  pregnant  women, 
who  are  at  the  same  time  albuminuric,  being,  in  general,  in  direct  rela- 
tion with  the  amount  of  albumin. 

3.  When  albuminuria  produces  serious  symptoms,  it  depends  upon,  not 
only  pregnancy,  but  also  a  serious  renal  affection,  which  may  progress 
after  confinement,  and  cause,  as  the  observations  of  Hoffmeier  prove,  the 
death  of  the  patient. 

4.  Labor,  as  we  have  seen,  has  a  marked  influence  in  the  production 
of  albuminuria  and  of  eclampsia;  and  as  the  induction  of  premature 
labor,  and  with  still  more  reason  abortion,  always  requires  a  certain 
length  of  time,  the  result  may  be  that  during  this  time  the  patient 
may  be  placed  in  a  condition  still  more  unfavorable  than  that  in  which 
she  already  is,  by  the  mere  fact  of  the  albuminuria  from  which  she  is 
suffering. 

Finally,  although  it  is  true  that,  in  a  number  of  cases,  albuminuria  has 
disappeared  after  the  death  of  the  foetus,  and  the  real  cessation  of  preg- 
nancy, there  are  many  other  instances  where  it  has  reappeared  at  the  onset 
of  labor,  accompanied  or  not,  by  eclampsia. 

But,  although  we  reject  the  induction  of  labor,  and  still  more  of  abor- 
tion, it  is  not  the  same  with  interference  after  labor  has  once  come  on. 
In  this  case  nature  herself  shows  the  way,  and  as  soon  as  possible  without 
danger  to  the  mother,  we  hasten  to  end  the  labor. 

But  we  never  interfere  before  dilatation  of  the  cervix  is  complete,  and 
if  the  contractions  are  energetic,  and  the  woman  a  multipara,  then  we 
should  leave  the  case  to  nature.  If,  on  the  contrary,  the  woman  is  a  pri- 
mipara,  and  labor  proceeds  slowly,  and  the  contractions  are  feeble,  as  soon 
as  the  dilatation  is  complete  or  the  cervix  largely  dilated  and  dilatable,  we 
end  the  labor  by  forceps  or  by  version.  It  is  finally  a  fact,  confirmed  by 
all  accoucheurs,   that  labor   generally  proceeds  rapidly  in  albuminuric 


DISEASES    OF    PREGXAXCY.  91 

"VTonien,  except  in  cases  of  dystocia,  and  this  gives  the  child  a  better 
chance  of  surviving. 

Eclampsia. 

Eclampsia  may  declare  itself  during  pregnancy,  labor  or  the  puerperal 
state.  Authorities  have  been  accustomed  to  describe  it  in  the  portion  of 
their  works  which  treats  of  Dystocia.  We  believe  it  more  rational  to  ar- 
range it  among  the  diseases  of  pregnancy,  on  account  of  the  intimate  re- 
lations which  exist  between  albuminuria  and  eclampsia.  As  we  have  said, 
if  all  albuminuric  women  are  not  eclamptic,  all  eclamptic  women,  with 
few  exceptions,  are  albuminuric,  and  eclampsia  is  only  one  of  the  manifes- 
tations of  albuminuria  in  women  during  pregnancy,  labor  or  the  puer- 
peral state.  We  think  that  it  is  of  advantage  not  to  separate  in  our  study 
these  two  diseases,  of  which  one  is  the  immediate  consequence  of  the 
other. 

Eclampsia  by  itself  does  not  impede  labor,  and  if  it  is  classified  by 
authors  with  dystocia,  it  is  not  as  an  obstacle  to  delivery;  it  is  an  acci- 
dent that  endangers  the  life  of  mother  and  child.  Although  eclampsia  is 
more  alarming,  generally,  after  confinement,  the  risk  which  the  mother 
and  child  incur  during  pregnancy  are  none  the  less  serious,  and  it 
ought,  as  Cazeaux  says,  on  account  of  the  seriousness  and  nature  of 
the  convulsions,  to  be  placed  at  the  head  of  the  diseases  of  pregnant 
women.  It  is  one  of  the  most  alarming  complications  of  albumin- 
uria gravidarum,  and  as  such  it  should  be  studied  immediately  after 
albuminuria. 

Definition. — Under  the  name  of  puerperal  convulsions,  acute  epilepsy, 
renal  spasm,  renal  epilepsy,  uraemic  convulsions,  acute  cerebral  uraemia, 
cerebral  uraemia,  cerebral  albuminuria,  epileptic  dystocia,  convulsive 
dystocia,  eclampsia  is  described  as  an  acute  disease  coming  on  during  preg- 
nancy, labor  or  the  puerperal  state,  and  characterized  by  a  series  of  tonic 
and  clonic  convulsions,  affecting  at  first  the  voluntary  muscles,  and  finally 
extending  to  the  involuntary  muscles,  accompanied  by  a  complete  loss  of 
consciousness,  and  ending  by  a  period  of  coma  or  sleep,  which  may  result 
in  cure  or  death. 

Frequency. — As  all  authorities  agree  in  regarding  eclampsia  as  a  rela- 
tively rare  accident,  it  is  difficult,  according  to  their  statistics,  to  establish 
an  approximate  estimate  even,  because  the  frequency  of  eclampsia  appears 
to  vary,  not  only  from  the  statistics  of  certain  authors,  but  also  even  in 
different  countries,  and  in  different  years.  Moreover,  if  eclampsia  ap- 
pears more  often  in  hospital  than  in  private  practice,  it  is  because  the 
cases  are  collected  from  different  parts  of  the  town,  and  brought  to  the 
hospital,  which  necessarily  increases  hospital  statistics.  Here  are  the  fig- 
ures resulting  from  the  practice  in  different  countries: 


92 


A    TREATISE    OTST    OBSTETRICS. 


In  France, 

England, 

Belgium, 

Switzerland 

Sweden 

Russia, 

Germany, 


457  cases  in  131,263  confinements. 


161  " 

"  66,744 

13  '• 

■'   1,750 

11  " 

"      6,139 

3  " 

502 

10  " 

^'   2,014 

76  " 

"  50,558 

731 


"  258,969 

or  about  1  case  in  354  confinements.  Peter  has  proved  tliat  the  cases  of 
eclampsia  are  becoming  more  and  more  frequent;  indeed,  taking  the  fig- 
ures given  by  Depaul  in  his  clinic,  and  which  represent  all  the  cases  ob- 
served in  the  hospital  from  1834  to  1871,  and  dividing  them  mto  periods  of 
ten  years,  Peter  has  arrived  at  the  following  result: 


From  1834  to  1843 
1844  "  1853 
1853  ''  1863 
1863  "  1871 


17  cases 

35    " 
54    " 


He  thinks  this  result  is  due  to  the  fact,  that  the  habit  of  bleeding  preg- 
nant women  who  suffer  from  this  complication  has  been  abandoned.  Ac- 
cording to  certain  authors,  finally,  eclampsia  becomes  more  and  more 
frequent  as  we  approach  the  equator.  Barquissau  quotes  in  connection 
with  this,  the  personal  observations  of  de  Mahy,  who  has  stated  that  at 
Bourbon  eclampsia  is  frequently  observed,  and  that  it  occurs  more  often 
in  the  higher  classes  and  among  the  negroes  than  in  the  middle  classes. 
Eclampsia,  as  we  have  seen,  may  appear  at  any  time  during  pregnancy, 
labor  or  the  puerperal  state;  but  if  authorities  agree  that  it  occurs  by  far 
most  frequently  at  the  moment  of  labor,  they  are  not  of  the  same  opin- 
ion concerning  its  frequency  during  pregnancy  and  the  puerperal  state. 
Thus,  while  the  majority  of  authors  arrange  the  order  of  frequency  as 
follows:  Labor,  puerperal  state,  pregnancy;  Bailly  proposes  to  substitute 
the  following  order:  Pregnancy,  labor,  puerperal  state.  Our  own  opin- 
ion would  lead  us  to  arrange  the  order  of  frequency  as  follows:  Labor, 
pregnancy,  puerperal  state. 

In  reality,  there  is  only  here  a  misunderstanding,  and  the  difference  of 
opinion  is  not  as  great  as  would  seem  at  first  sight.  We  consider  eclamp- 
sia as  closely  allied  to  albuminuria.  Now  all  authors  agree  on  this  point: 
that  the  albuminuria  of  labor  is  more  frequent  than  the  albuminuria  of 
pregnancy,  that  it  is  at  the  same  time  more  serious.  It  is  not  remarka- 
ble then  that  eclampsia  shows  itself  more  frequently  during  labor.  But, 
on  the  other  hand,  under  the  name  of  albuminuria  of  labor,  authorities 
generally  mean  that  which  appears  during  the  two  or  three  days  before 
labor,  days  which  correspond  to  the  period  which  Millot  calls  the  period 
of  secret  labor,  and  these  days  belong  as  much  to  pregnancy  as  to  labor. 

As  a  rule,  further,  labor  comes  on  at  the  end  of  a  certain  number  of 


DISEASES    OF    PKEGNx\.JSrCY. 


93 


eclampsic  attacks;  and  lastl}^,  delivery  does  not  always  suppress  these  at- 
tacks^ which  are  then  seen  to  return  either  in  greater  or  less  numbers 
than  before  delivery.  Hence  the  differences  of  opinion.  G-roup  the 
attacks  together,  and  the  eclampsia  of  labor  becomes  the  much  more  fre- 
quent. If  we  separate,  on  the  contrary,  the  three  periods  distinctly, 
Bailly  gets  nearer  to  the  truth,  which  appears  to  us  to  be  the  division 
which  we  have  given — Labor,  pregnancy,  puerperal  state. 

This  seems  to  be  the  result  of  the  various  statistics  in  the  following 
table,  which  we  have  taken  from  Wieger. 


Before 

and  during  labor.  * 

Puerperium. 

Total 
number. 

Collins 

28 

2 

30 

MacClintock 

8 

5 

13 

Rose 

8 

4 
16 

12 

Before  labor. 

During  labor. 

Mauriceau 

7 

19 

43 

Jaccoud      .... 

18 

20 

9 

47 

Velpeau      .... 

7 

5 

9 

31 

Desjardin    .... 

0 

5 

2 

7 

Lever 

3 

10 

2 

15 

Ramsbotham      . 

17 

28 

14 

59 

Before 
labor. 

During 

1st  stage 
of  labor. 

During 
expulsion. 

During 
3d.  stage. 

During 
puerper- 
ium. 

Schwartz    .... 

2 

3 

5 

1 

11 

Arneth        .... 

1 

7 

3 

2 

13 

Lachapelle .... 

4 

4 

4 

3 

1 

16 

Braiin          .... 

12 

11 

10 

3 

8 

44 

Devilliers  and  ) 
Regnault.          C ' 

2 

6 

2 

0 

1 

11 

Blot 

1 

3 

2 

1 

7 

Divers         .... 

36 

21  my 

7 

4 

23 

108 

Thus,  in  a  total  of  455  cases  of  eclampsia,  109  occurred  before  labor,  336 
during  labor  and  110  after  the  birth  of  the  child, 

Jacquemier  found  99  cases  during  labor,  53  cases  during  pregnancy,  45 
cases  after  labor.  Depaul  confines  himself  to  cases  before  and  after  labor, 
and  in  133  cases  there  were  106  cases  before  labor,  and  77  after  labor. 
Of  the  77  cases,  in  9  only  did  the  attacks  appear  first  after  labor,  with- 
out giving  any  signs  of  eclampsia  before  labor. 

In  62  cases  there  were  attacks  before  labor  which  continued  after.  In 
11  cases  the  attacks,  which  existed  before  and  during  labor,  were  not  pro- 
duced after  labor.  The  other  cases  refer  to  women  brought  to  the  Clinic, 
without  information  concerning  the  possible  attacks  before  labor.  The 
following  then  are  the  figures: 

In  133  cases  attacks  before  labor,  106;  after  labor,  77;  first  commenc- 


'  The  period  of  labor  is  not  specified  in  these  17  cases. 


94 


A   TEEATISE    OTT    OBSTETEICS. 


ing  after  labor  9;  ceasing  after  labor,  11;  before^  during,  and  after  labor, 
62. 

It  is  rare  before  the  sixth  month;  although  Danyau  has  seen  a  case  in 
the  sixth  week;  Bach  in  the  sixth  week;  Prestat  in  the  second  week; 
Morel  d^Argentan  in  the  fourth  month;  Carville  in  the  fifth  month; 
Charpentier  in  the  fifth  month;  Cohen  fifth  and  sixth  month;  Devilliers 
and  Eegnault  sixth  month.  The  rule  is  that  eclampsia  manifests  itself 
from  the  seventh  to  the  ninth  month,  particularly  a  few  days  before  labor. 

As  to  the  appearance  of  eclampsia  after  delivery,  as  a  rule,  the  attacks 
are  only  the  prolongation  of  those  which  existed  during  pregnancy,  but 
even  then  the  attacks  may  be  immediate  or  a  few  hours  after  confine- 
ment. We  have  seen  one  case  in  which  the  attacks  came  on  after  a  lapse 
of  twenty-four  hours.  When  the  attacks  come  on  for  the  first  time  after 
labor,  they  may  be  at  a  greater  or  less  interval  after  labor.  Wieger  in  44 
cases  has  noted  the  following  in  regard  to  commencement:  At  the  end  of 
4  hours,  8;  12  hours,  2;  24  hours,  1;  48  hours,  3;  4  days,  2;  10  days,  1. 
The  invasion  may,  however,  be  much  more  slow.  Thus:  Eamsbotham 
has  seen  it  7,  9,  10,  18  days  after  labor;  Ducheck  at  10  and  14  days  after 
labor.     The  women  remained  hemiplegic. 

Cazeaux  has  seen  it  8,  10,  12  days  after  labor;  Charpentier  at  17  and 
19  days;  Tissier  at  17days;  Baillyat29  days;  Simpson  at  8  weeks.    (Died.) 

In  1872,  we  analyzed  133  cases  collected  in  the  Clinic  by  Dr.  De  Soyre, 
and  these  are  the  figures  for  the  time  of  pregnancy  at  which  the  attacks 
showed  themselves. 

Primiparae  eclamptic  before  labor. 
At  5  months,        .         .         2 " 
"  5^     ''' 
"  6       " 
"  6i     " 

C£      t^  1  ii 


1 

6 
2 
6 
3 
19 
20 
1 


abor. 

Multi  parse  eclamptic  before  labor. 

At  6  months,       .         .         1  ^ 
''  6i     "     .         .         .         1 

"  7       "     .         .         .         5 
"  7i     "     .         .         .         3 

>     20 

>   60 

"  8       "     .         .         .         6 
"  8i     "     .         .         .         4j 

Multipara  eclamptic  at  term 

,     10 

Primiparse  eclamptic  at  term.,  43 


Total, 


133 


Causes. — A  great  fact  governing  all  causes  of  eclampsia,  is  the  almost 
constant  presence  of  albumin  in  the  urine  of  the  patient.  Excepting, 
indeed,  a  certain  number  of  cases  of  albuminuria,  which  we  cited  above, 
albumin  is  always  found  in  the  urine  of  eclamptic  cases,  and  these  cases 
are  too  few  in  number,  compared  witli  tiie  others,  not  to  be  taken  as  ex- 
ceptions, and  still,  as  Cazeaux  says,  all  are  not  absolutely  authentic. 

The  quantity  of  albumin  found  in  the  urine  increases  a  great  deal  dur- 
ing the  attack,  and  diminishes  usually  afterward. 

Aside  from  this  great  primary  cause,  authors  have  noted  the  following: 

Mafmer  of  Living. — Young  mothers  are  more  subject  to  it  than  others, 


DISEASES    OF    rREGNANCY. 


95 


but,  as  Wieger  observes,  poverty  may  contribute  to  it,  particularly  grief, 
and  the  more  so  as  the  primiparse  are  young  mothers. 

Epidemics. — This  inference  is  admitted  by  Wieger,  Mende  and  Man- 
sell,  who  base  their  judgment  on  the  frequency  of  eclampsia  at  certain 
times,  as  observed  by  authors;  but  the  epidemic  influence  of  eclampsia 
seems  to  me  to  belong  in  the  same  category  as  the  influence  of  seasons  and 
imitation. 

Age.  — This  does  not  appear  to  have  any  great  influence  as  a  cause, 
although  it  is  between  twenty  and  thirty  years  that  eclampsia  is  most 
frequent,  but  this  is  not  surprising,  since  it  is  at  this  age  that  women  are 
more  likely  to  become  pregnant. 

In  148  cases,  Wieger  found  37  cases  from  15  to  20;  63  cases  from  20  to 
25;  26  cases  from  25  to  30;  20  cases  from  30  to  40,  and  2  cases  from  40  to 
46. 

Peimipaeity. 

This  is,  without  doubt,  the  most  frequent  predisposing  cause.  Most 
authors  will  agree  in  this.     Thus 


Arneth, 

Blot, 

Briiun, 

Chailly, 

Clarke, 

Collins, 

Develliers  and  Eegnault, 

Jacquemier, 

Johns, 

Kobert  Lee, 

Lever, 

MacClintock  and  Hardy, 

Merriman, 

F.  Eamsbotham, 

J.  Eamsbotham, 

Colles  Eose, 

Divers, 

Depaul, 

Scanzoni, 

Totals, 


Priniiparse    Multiparee.    Total. 


6 
38 

9 
16 
73 
10 
13 
19 
30 

8 
10 
36 
43 
15 

9 

53 

103 

23 

522 


3 
1 
6 
9 
3 
12 
2 
4 
2 

16 

6 

3 

12 

14 

7 

3 

23 

30 

5 


161 


11 
7 
44 
18 
19 
85 
12 
17 
21 
46 
14 
13 
48 
57 
22 
12 
76 
133 
28 

683 


161  multiparee  against  522  primiparae,  or  3.22  primiparse  to  1  multi- 
para. 

This  proportion  -would  be  too  low  for  Madame  Lachapelle,  who  puts  it 
as  high  as  7  primiparae  to  1   multipara.     Usually  women  who  have  had 
eclampsia  in  their  first  confinement,  are  secured  from  having  it  in  subse 
quent  confinements,  but  it  is  not  always  so,  for  Collins,  Devilliers,  Schwartz, 
Johns,    Braun,   Dewees,  Eamsbotham,   Litzmann,  have  reported  cases. 


96  A    TREATISE    ON    OBSTETRICS. 

This  is  not  surprising.  If  we  admit  the  relation  of  albuminuria  to  eclamp- 
sia, albuminuria  does  not  always  appear  in  subsequent  confinements,  and 
the  women  escape  eclampsia;  if,  on  the  contrary,  albuminuria  does  reap- 
pear, nothing  is  more  natural  than  to  have  eclampsia  also.  This  explains 
cases  apparently  irregular,  in  which  the  first  pregnancy,  being  compli- 
cated by  eclampsia,  a  second  is  passed  without  any  accidents,  which,  how- 
ever, appeared  in  a  subsequent  pregnancy.  Cases  are  seen  in  which  a 
woman  escapes  eclampsia  in  her  first  confinement,  and  has  it  in  her  second, 
third,  fourth  and  even  the  eleventh,  as  Dumont  has  stated. 

Distension  of  the  Utems. — Along  with  primiparity,  which  acts,  accord- 
ing to  many,  through  the  great  resistance  of  the  uterine  fibres,  must  be 
placed  excessive  distension  of  the  uterus  dependent  upon  the  large  size  of 
the  child,  twin  pregnancies,  hydramnios;  finally,  different  causes  whose 
action  is  much  less  evident,  i.e.,  erosions,  fright,  indigestion,  and  retention 
of  nrine. 

The  Length  of  Labor. — Labor  may  be  prolonged  by  the  causes  given 
above,  by  mechanical  causes,  deformed  pelvis,  uterine  and  abdominal 
tumors.  The  influence  of  the  length  of  labor  in  the  production  of  eclamp- 
sia is  undisputed.  But  eclampsia,  we  have  seen,  is  produced  often  dur- 
ing pregnancy,  and,  when  labor  comes  on  in  these  cases,  it  was  gener- 
ally rapid,  unless  there  was  some  mechanical  obstacle;  and  one  of  the 
proofs  that  eclampsia  is  not  always  connected  with  labor,  is,  that  there 
are  a  great  many  cases  in  which  eclampsia,  coming  on  during  pregnancy, 
has  not  brought  about  confinement,  which  only  takes  place  later.  Most 
often  the  child  dies,  the  eclampsia  ceases,  and  the  woman  is  delivered 
later  of  a  dead  child,  changes  in  which  are  the* more  pronounced  the 
greater  the  length  of  time  between  its  death  and  its  expulsion.  We  have 
had  one  case  in  our  Clinic.  The  woman  was  confined  eight  days  later; 
and  to  this  case  we  can  add  those  of  Lever,  Litzmann,  Wegscheider, 
Lachapelle,  Boer,  Braiin,  Lauer,  Mauer,  Eodenstein,  Baschwitz;  and 
finally,  Simon, Devilliers  and  Eegnault,  Blot  and  Wieger,  have  cited  cases  in 
which  the  eclampsia  came  on  during  pregnancy,  did  not  bring  about  labor, 
and  in  which  the  women  were  delivered  later  of  living  children.  In 
each  of  these  cases  the  eclampsia  was  reproduced  neither  during  labor  nor 
after  confinement. 

What  are  then  the  determining  causes  of  eclampsia  ?  We  must  remem- 
ber here  all  the  causes  we  mentioned  under  albuminuria,  i.e.,  alteration 
of  the  blood,  increase  of  blood  pressure  and  renal  lesions,  etc.,  but  if  those 
theories  account  for  albuminuria,  they  do  not  suffice  to  show  why  eclamp- 
sia occurs  in  certain  cases,  and  why  it  is  wanting  in  others,  and  so  the  aim 
has  been  to  discover  the  true  cause  of  eclampsia;  hence  the  new  theories 
which  Bailly  classifies  under  the  following  heads:  Eclampsia  is  due:  1. 
To  a  structural  change  in  the  nerve  centres  and  their  envelopes;  2.  A 
cerebro-spinal  congestion;    3.   Eclampsia  is  a  neurosis,  caused  by  a  reflex 


DISEASES    OF    PREGIN'ANCY.  97 

irritation  of  the  spinal  S3^stem,  originating  in  nterine  pain;  4.  To  a  gen- 
eral or  cerebral  anaemia:  5.  To  a  condition  of  the  blood  which  renders 
this  fluid  less  ready  to  stimulate  regularly  the  nerve  centres  (uremia, 
ammontemia,  urinaemia.) 

Depaul  and  Ilypolitte  have  endorsed  these  divisions  of  Bailly.  All 
of  them  we  think  are  open  to  objections  more  or  less  grave.  As  Cazeaux 
has  stated,  all  these  causes  may  act  in  ]3roducing  an  irritation  of  the  nerve 
centres,  and  Scanzoni  has  already  tried  to  show  that  this  convulsive  attack 
is  due  to  an  excitation,  an  irritation  of  the  peripheral  nerves,  and  of  those 
of  the  spine  or  brain. 

It  has  been  shown,  he  says,  that  the  sensory  nerves,  extending  into  the 
walls  of  the  uterus,  may  at  once,  by  irritation  excited  in  them  during 
pregnancy  and  labor,  produce  a  reflex  action  on  the  motor  nerves  which 
are  given  off  from  the  spine.  Admit  this,  and  it  is  no  longer  doubted 
that  this  reflex  action,  under  the  influence  of  extreme  congestion,  (renal 
hypertemia),  which  may  increase  the  excitability  of  the  general  nervous 
system,  niay  go  beyond  its  normal  limits  and  produce  contractions,  con- 
vulsions, of  the  muscles  supplied  by  these  nerves.  If  the  excitation  pro- 
duced in  the  sensory  nerves  of  the  uterus  is  not  extreme,  or  even  limited 
to  a  small  part  of  the  sensory  nerves,  these  reflex  movements  will  be  pro- 
duced in  the  voluntary  muscles  only  to  a  very  limited  extent.  This  is  con- 
firmed every  day  by  cramps  that  are  observed  in  the  lower  extremities, 
where  terminal  spinal  nerves  are  distributed.  If  the  irritation  increases 
and  extends,  reflex  convulsions  may  be  seen  in  the  muscles  of  the  trunk. 
This  increase  of  sensory  uterine  irritation  during  labor  may  be  produced 
by  all  the  causes  which  may  make  traction  on  or  compress  the  nervous 
filaments  during  the  uterine  contractions.  Thus  we  see  these  convulsions 
occur  in  parturient  women,  in  cases  of  mechanical  obstruction  to  labor, 
which  exerts  on  the  uterus  a  greater  force  than  customary;  when  the  uterine 
wall  is  in  close  apposition  to  the  child,  and  makes  considerable  pressure. 

It  is  the  same  when  it  is  an  isolated  part  of  the  organ  which  is  exposed 
to  those  causes  of  excitement,  (inferior  segment  of  uterus  in  the  vicinity 
of  the  OS  internum.)  All  the  causes  which  lessen  dilatation  may  also 
provoke  convulsions,  partly  because  the  inferior  segment  of  the  uterus  is 
compressed  in  a  marked  degree  by  the  uterine  contents,  and,  partly,  because 
the  longitudinal  fibres  which  produce  the  dilatation  are  exposed  to  in- 
creased tractions.  This  is  one  of  the  reasons  which  explain  the  greater 
frequency  of  eclampsia  in  primipara?.  Finally,  as  a  cause  favoring  con- 
vulsions, we  must  mention  spasmodic  contractions  of  the  os  externum, 
and  all  those  causes  which  produce  rigidity.  Moreover,  extraneous  causes, 
foreign  to  the  mother,  may  produce  this  excessive  irritability  of  the  uter- 
ine nerves,  and  lead  to  convulsions  by  reflex  action,  i.e.,  manual  or  in- 
strumental dilatations  of  the  cervix.  The  central  nervous  irritation  may 
react  either  on  the  spine  or  brain. 
Vol.  II. —7. 


98  A.   TEEATISE    O^    OBSTETEICS. 

As  for  the  spine,  we  must  consider  hyperemia  of  the  cord  and  its  mem- 
branes. A  ]))'iori,  it  may  he  admitted,  that  the  same  canses  which,  dur- 
ing pregnancy  and  confinement,  lead  to  congestion  of  the  abdominal 
viscera,  and  particularly  the  kidneys,  may  produce  congestion  of  the  lower 
segment  of  the  cord;  and  experience  has  shoAvn  that  pregnancy  is  accom- 
panied almost  always  by  congestion  in  the  lower  part  of  the  cord.  But 
no  doubt,  hyperfemia  in  this  part  of  the  cord  does  not  favor  convulsions. 
Vie  must  admit  that  a  woman,  during  pregnancy,  confinement  and  the 
puerperal  state,  is  predisposed  more  than  in  all  other  conditions  to  these 
convulsions.  It  is,  however,  understood  that  these  congestions,  to  cause 
these  convulsions,  must  not  exceed  a  certain  degree,  and  must  not  be  ac- 
companied by  exudations  into  the  medullary  tissue  or  the  arachnoid  sac, 
for  otherwise  we  would  not  have  convulsions,  but  paralysis.  Finally,  no  one 
doubts  but  that  the  medullary  irritation  causing  convulsions  must  have 
its  origin  in  the  brain. 

Eclampsia  then  may,  according  to  Scanzoni,  show  itself  in  three  forms: 
1st.  Keflex  convulsions  arising  from  the  peripheral  extremity  of  the  uter- 
ine sensory  nerves;  2d.  Spinal  convulsions  arising  from  the  direct  irrita- 
tion of  the  spinal  cord,  an  irritation  which  is  referred  to  the  peripheral 
extremities;  3d.  Cerebral  convulsions,  when  the  irritation  arises  in  the 
brain,  and  is  referred  to  the  spinal  cord. 

Cazeaux  says  that  this  last  form  may  be  controverted,  and,  according 
to  him,  spinal  irritation  is  always  the  origin  of  eclamjDsia.  '^  It  is  a  fact 
established  by  all  physiologists,  that  the  irritation  of  the  cord,  medulla,  or 
tubercula  quadrigemina,  alone  causes  convnlsions,  while  irritation  of  other 
points  of  the  cerebrum  or  cerebellum  produce  nothing  similar.  Cerebral 
lesions  may  indeed  destroy  voluntary  movements,  but  the  involuntary  con- 
tractions, those  of  which  the  excess  and  irregularity  constitute  eclampsia, 
are  not  affected.  These  last  may  still  be  produced  by  spinal  irritation  or 
of  its  nerves  Avhen  the  brain  and  cerebellum  have  been  destroyed.'^ 

In  1875  Cohen  of  Hamburg  proposed  two  original  ideas,  of  which  we 
will  speak  in  a  few  words.  According  to  him  there  are  two  kinds  of 
eclampsia:  "  Uterine  eclampsia,  which  may  be  produced  by  irritation  of 
the  uterus,  referred  secondarily  to  the  brain;  cerebral  eclampsia,  which,  on 
the  contrary,  originates  in  the  brain,  and  is  referred  secondarily  to  the 
uterus,  thus  causing  convulsions.  These  two  forms  are  found  clinically. 
Uterine  eclampsia  is  divided  into  two  classes,  one  which  is  called  uterine 
eclampsia  at  term,  which  results  in  phenomena  which  occur  during  labor 
and  confinement;  the  other  eclampsia  before  term,  which  depends  upon  the 
contact,  at  the  end  of  the  sixth  month,  between  the  foetus  and  the  inferior 
segment  of  the  uterus,  and  on  the  distension  and  change  of  form  which 
the  lower  uterine  segment  undergoes.  This  form  Avill  give  a  favorable 
prognosis  for  mother  and  child;  the  other,  cerebral  eclampsia,  depends 
upon  a  cerebral  affection,  and  presents  some  of  these  signs  from  the  outset. 


DISEASES    OF   PKEGJN^ANCY. 


99 


111  tliis  case  there  is  either  abortion  or  premature  labor,  or  labor  at  term; 
and  this  confinement  may  either  lead  to  a  favorable  ending  of  the  cere- 
bral affection,  or,  on  the  contrary,  may  aggravate  and  hasten  the  death  of 
mother  and  child.  The  following  are,  according  to  him,  characteristic 
symptoms,  which  enable  us  to  differentiate  these  two  eclampsias. 

Differential  Diagnosis  of  Uterine  and  Cerebral  Eclampsia. 

UTERTISTE    ECLAMPSIA    AT   TERM.  CEREBRAL    ECLAMPSIA. 


1.  Begins  at  term. 

2.  Each  attack  is  accompanied 
by  contraction  of  the  uterus,  recog- 
nized through  the  abdomen. 

3.  Eclampsia  disappears  with 
birth  of  child  and  placenta,  and 
after  uterine  contractions  cease. 

4.  Convulsions  come  on  gradual- 
ly and  increase. 

5.  The  remission  resembles  sleep 
without  coma. 

6.  Eotation  of  head  only  in  very 
marked  cases. 

7.  Earely  is  the  protrusion  of  the 
tongue  very  marked,  as  well  as  the 
closure  of  the  jaws. 

8.  Excretions  rarely  involuntary. 


9.  Dilatation  of  the  cervix  goes 
on  continually. 

10.  Obstetrical  intervention  acts 
favorably,  particularly  in  hydra  m- 
nios, 

11.  The  convulsions  are  always 
preceded  by  nervousness,  by  groans. 

12.  The  duration  rarely  exceeds 
a  day. 

13.  The  child  is  born  alive,  the 
mother  usually  recovers. 

14.  Rarely  in  multiparas  does  the 
OS  remain  closed. 

UTERINE  ECLAMPSIA  BEFORE  TERM. 

1.  Begins  at  end  of  6th  month. 

2.  No  true  coma,  no  involuntary 
excretions,  no  jorotrusion  of  the 
tongue. 

3.  Caused  by  the  descent  of  the 
child. 

4.  Action  of  narcotics  rapid. 


1.  Begins  at  any  period  of  preg- 
nancy or  puerperal  state. 

2.  Each  attack  comes  on  suddenly 
with  uterine  contractions. 

3.  The  attack  may  come  on  after 
labor  or  in  the  puerperal  state. 

4.  The  attack  reaches  its  acme 
suddenly. 

5.  Coma  profound ;  stertorous 
breathing. 

6.  Rotation  of  the  head  very 
marked. 

7.  Always  protrusion  of  the  tongue 
and  spasmodic  closure  of  the  jaws. 

8.  Excretions  involuntary  imme- 
diately after  the  beginning  of  the 
attack. 

9.  The  cervix  remains  closed 
during  the  attack,  which  lasts  some 
hours  or  days;  the  cervix  dilates 
suddenly. 

10.  Obstetrical  intervention  while 
labor  is  not  at  hand  is  useless. 

11.  No  nervousness,  no  groans. 

12.  The  convulsions  last  a  long 
time. 

13.  The  child  generally  dies,  the 
mother  often. 

14.  As  frequently  in  multiparse 
as  in  primiparge. 


1 .  At  any  period  of  pregnancy. 

2.  Cerebral  symptoms  very  well 
marked. 

3.  Caused    by    Bright's   disease, 
fright,  mental  emotions. 

4.  Narcotics  often  without  action. 


100  A   TEEATISE    ON    OBSTETRICS. 

In  makiDg  a  division  so  well  marked  Cohen  goes  mricli  too  far,  but, 
without  sharing  his  views,  one  must  confess  that  eclampsia  is  far  from 
being  always  the  same  in  its  characteristics,  and,  while  preserving  its  gene- 
ral characteristics,  the  attacks  may  vary  in  different  women,  or  even  in 
the  same.  How,  on  the  one  hand,  can  the  attack,  so  frequent  in  some 
women,  be  explained,  and  so  rare,  on  the  contrary,  in  others  ?  Why,  in 
some  women,  does  labor  come  on  after  a  few  attacks,  while  in  others, 
who  have  a  great  many  attacks,  labor  does  not  come  on?  Why  does  the 
child  die  so  quickly  in  some  cases,  and  in  other  cases  survive  so  long  ? 
Why  do  certain  women  die  after  8  or  10  attacks,  and  others  have  30,  40, 
50,  60  or  100  attacks  or  even  more,  and  still  live,  as  has  been  shown  by 
Pajot  and  Bailly?  These  questions  are  so  numerous  that  it  is  impossible 
to  answer  them  definitely. 

1st.  Eclani'psia  is  due  to  an  Alteration  of  the  Nerve  Centres  and  their- 
Envelopes. — Supported  by  Marchal  de  Oalvi  in  1851,  this  theory  has  against 
■  it,  as  Hypolitte  has  observed,  the  results  of  autopsies^  for  the  lesions  met 
with  do  not,  as  a  rule,  exist  in  the  spine,  the  medulla,  or  the  tubercula 
quadrigemina,  which,  according  to  physiologists,  are  alone  capable  of 
producing  the  convulsions.  Coindet  and  Odier,Grisolle,  Hardy  and  Behier, 
Graves,  Cahours,  explain  the  encephalopathy  by  hydrocephalus;  Owen, 
Eees,Traube,  as  cerebral  cedema  due  to  Bright's  disease,  and  the  experi- 
ments of  Munck  (who  injected  water  into  the  carotids,  first  having  ligated 
the  ureters  and  jugular  veins),  seems  to  confirm  this  view.  Otto,  Bidder, 
performing  these  experiments,  without  ligating  the  ureters  or  jugulars, 
have  shown  that  the  increase  of  pressure  did  not  produce  the  convulsions, 
and  that  there  must  be  concomitant  hydrsemia.  It  is  on  this  fact  that 
Traube  bases  his  theory  of  cerebral  oedema  with  subsequent  acute  anae- 
mia. To  explain  this  cerebral  oedema,  Traube  invokes  first,  the  hydrae- 
mia  shown  to  exist  by  Andral,  Gavarret,  Devilliers  and  Eegnault;  and 
secondly,  an  increase  of  the  intra- vascular  pressure,  due  to  the  cardiac 
hypertrophy  of  pregnant  women,  and  the  increased  tension  of  the  cerebral 
vessels,  produced  by  the  pressure  of  the  uterus  on  the  abdominal  aorta  at 
the  end  of  gestation. 

Hypolitte  says,  that  there  are  certain  forms  of  eclampsia,  which  seem 
at  first  sight  to  justify  this  theory.  "  Those,  for  instance,  where  the  urine 
is  diminished  to  1500  grains  per  day.  This  urine  is  concentrated,  and 
the  dropsy  (oedema)  diminishes  generally  before  the  cerebral  complications 
appear.  Dropsy  then  spreads  from  the  lower  extremities  to  the  brain. 
This  is  the  mechanical  ura3mia  of  Jaccoud;  but,  as  Hypolitte  has  observed, 
hydrocephalus,  and  oidema  of  the  brain  or  its  membranes,  far  from  produc- 
ing excitement  or  twitchings,  seem,  on  the  contrary,  to  produce  weak- 
ness.    Convulsions  are  not  the  result,  but  paralysis." 

JSTevertheless,  Traube's  theory,  if  it  does  not  apply  to  all  cases,  may  at' 
least  explain  a  great  number,  for  it  is  supported  by  undoubted  clinical 


DISEASES    OF   PREGNANCY.  10 i 

facts^  and  we  can  not  compare,  as  Hypolitto  lias  done,  the  acute  cedema 
of  Traube  to  tlie  chronic  cjedema  of  the  paralytic, 

2d.  Eclam2)sia  is  clue  to  a  Cerebrospinal  Congestion. — Originated  by 
Manriceau,  defended  by  Levret,  Broussais,  Blot,  Peter,  this  theory  is 
denied  by  Hypolitte,  Testut,  Depaul,  who  consider  the  cerebral  conges- 
tion and  cerebral  hemorrhage,  which  have  been  found  on  autopsies,  the 
result  and  not  the  cause  of  convulsions.  We  will  see  further  on  that 
the  course  of  the  temperature,  very  different  in  cerebral  hemorrhage  and 
in  eclampsia,  justifies  the  opinion  of  the  latter  authorities.  But  is  not  the 
eclampsia  due  to  a  rachidian  hyperemia,  resulting  from  an  irritation  of 
the  cerebro-spinal  system,  or  the  sensory  terminal  filaments  ?  This  brings 
us  to  the  third  theory. 

3d.  Eclampsia  is  a  Netirosis,  by  a  reflex  Irritation  of  the  spinal  System, 
whose  Point  of  Origin  resides  in  the  Uterine  Pains. — This  is  the  opinion, 
formally  upheld  by  Tissot,  Cullen,  Vogel,  Sydenham,  Sennert,  Jacque- 
mier,  and  revived  by  Dubois,  Scanzoni,  Axenfeld,  Marshall  Hall,  Tyler 
Smith,  Fleetwood  Churchill,  and  refuted  by  Depaul,  Bailly  and  Hypolitte. 

As  Depaul  observes  with  reason,  if  one  admits,  with  the  advocates  of 
this  theory,  the  irritation  of  the  nerves  of  the  uterus  or  pelvic  cavity,  by 
the  increased  growth  of  the  uterus,  or  the  action  of  the  parturient  state, 
"  Why  are  not  all  primiparse  eclampsic,  since  in  them  the  uterus  is  en- 
larged for  the  first  time  ?  Why  are  not  all  rachitic  cases  eclampsic  ?  We 
have  already  seen  that  this  last  cause  is  more  rare  than  we  generally  be- 
lieved. That  all  these  conditions  may  predispose  to  eclampsia,  I  grant; 
but  there  must  be  other  causes  added  to  produce  convulsions.  It  is  this 
other  cause  that  I  look  for  in  this  theory  and  do  not  find;  and  further, 
How  explain  an  eclampsia  which  may  occur  during  the  puerperal  state, 
when  the  irritation  of  the  uterine  nerves  is  not  present  ?  If  the  Marshall 
Hall  theory  is  rightly  established,  it  must  still  fall  to  the  ground,  since 
this  author  pretends  that  no  lesion  of  the  brain  or  cerebellum  can  give 
rise  to  convulsions  if  the  spine  is  secure  from  irritation.  And  so  Tyler 
Smith  believes  convulsions  to  be  due  to  a  reflex  irritation  of  the  spine 
through  the  nerves  of  the  uterus.  I  would  answer  him  even  as  I  have 
Axenfeld  in  regard  to  his  theory. 

"I  do  not  see  what  can  be  the  cause  of  this  irritation  of  the  nerves  of 
the  uterus,  when  I  remember  that  eclampsia  may  be  developed  before  the 
beginning  of  labor,  or  even  of  the  puerperal  state.  Some  interesting  ex- 
periments have  lately  been  made  on  this  reflex  power,  but  every  time 
that  the  convulsive  movements  were  produced,  they  were  partial  and  not 
general,  aside  from  the  fact  that,  where  a  like  result  has  been  reached, 
the  point  of  origin  is  known,  and  one  can  localize  the  irritation  on  such 
or  such  point  of  the  organism.  Is  it  the  same  with  eclampsia  ?  What  is 
this  pretended  irritation  of  the  nerves  of  the  uterus  ?  Are  not  all  women 
in  a  like  situation?     Labor  produces  in  all  very  severe  pains;  the  cervix 


102  A   TREATISE   ON   OBSTETEICS. 

itself  is  irritated  where  we  aim  at  the  induction  of  premature  labor;  and 
yet,  is  it  common  to  produce  eclampsic  attacks  ?  It  is  not  then  in  the 
uterus  that  we  must  look  for  the  causes  of  this  accident,  because,  although, 
sometimes  we  see  convulsions  following  on  a  severe  pain,  how  many  times 
under  other  circumstances,  do  we  see  the  disease  develop  before  the  be- 
ginning of  labor,  or  even  after  delivery. 

"Further  still,  much  has  been  said  about  the  accumulation  of  faeces  in 
the  rectum,  of  foreign  bodies  in  the  intestine,  of  worms,  of  emotions, 
etc.  But  I  will  not  expatiate  on  this  point.  I  do  not  think  that  simple 
sympathetic  phenomena  can  be  invoked  to  explain  the  etiology  of  eclampsia, 
and  I  reject  as  well  the  neurosis,  by  the  reflex  action  on  the  cerebro- 
spinal system,  as  the  neurosis  essential  to  the  acute  stage.  ^'     (Depaul.) 

4.  General  or  cerebral  Anoemia  is  the  Cause  of  Eclampsia. — According 
to  Fournier,  Traube,  See,  the  phenomena  of  eclampsia  (uraemic  eclamp- 
sia, i.e.,  blood  poisoning)  are  analogical,  from  the  point  of  view  of  the 
particular  mode  of  their  production,  with  the  pathological  process,  which 
Kussmaul,  Tenner  and  others,  assign  to  epilepsy.  By  the  altered  state 
of  the  blood,  there  is  produced  an  irritation  of  the  vaso-motor  nerves  of 
the  cerebral  arteries;  these  arteries  contracting,  there  result,  either  con- 
vulsions from  oligemia  of  the  cord,  or  coma  from  oligemia  of  the  brain. 

Testut,  who  is  an  advocate  of  the  reflex  action,  admits  that  it  produces 
angemia  of  the  brain.  "  Instead  of  being  arrested  in  the  cells  of  the  sen- 
sory and  motor  columns  of  the  cord,  the  irritation  from  the  uterus  is  car- 
ried quickly  toward  the  vessels  of  the  mesophalon,  and  causes  the  elements 
of  its  muscular  tissue  to  contract,  and  anaemia  of  this  portion  of  the  brain 
resulting,  the  conditions  are  evoked  on  which  stress  has  been  laid  by 
Kussmaul  and  Tenner  for  the  development  of  epileptic  attacks." 

Before  considering  the  last  cause  of  eclampsia,  the  poisoned  state  of 
the  blood,  it  is  necessary  here  to  return  to  the  '*'  renal  theory, ''the  theory 
which  we  have  spoken  of  in  detail,  in  the  chapter  devoted  to  the  study 
of  albuminuria.  Let  us  remember  only  that,  while  certain  authors  de- 
clare that  there  is  no  eclampsia  without  albuminuria,  and  no  albuminuria 
without  a  renal  lesion,  others,  whose  authority  is  no  less,  do  not  share 
this  view,  and  that  the  latter  oppose  to  the  first  the  relatively  numer- 
ous cases  where  there  has  occurred  eclampsia  without  albuminuria.  These 
cases  have  been  multiplied  during  the  last  years;  and  it  will  be  sufficient 
to  refer  to  141  cases,  which  we  have,  taken  from  the  literature  on  the 
subject,  and  if  some  of  the  cases  may  be.  doubted,  the  greater  number 
offer  well-authenticated  characteristics.  Eenal  lesion  is  not,  therefore, 
constant  in  eclampsia.  Also  certain  authors  have  gone  still  further,  and 
have  declared,  that  it  was  not  only  not  albuminuria  which  produced 
eclampsia,  but  eclampsia  which  predisposed  the  patient  to  albuminuria. 
Blot  and  Depaul  have  already  noted  the  increase  of  albumin  during  the  at- 
tacks, and  often  also,  albuminuria,  which  did  not  exist  before  the  con- 


DISEASES    OF   PREGNANCY.  103 

vnlsions  has  shown  itself,  and  disappeared  with  them.  This  they  call 
nervous  albuminuria,  and  three  possible  causes  are  assigned  to  it:  lesion 
of  the  renal  tierves,  those  of  the  splanchnic,  and  the  floor  of  the  fourth 
ventricle.  The  experiments  of  Wittich,  of  Herman,  of  Ludwig,  of 
Stokvis,  have  only  confirmed  those  of  CI.  Bernard  as  to  lesions  of  the 
floor  of  the  fourth  ventricle  being  sufficient  to  produce  albuminuria;  and 
Paul  Dubois  has  said  in  his  clinical  lessons:  '"  Since  numerous  experi- 
ments have  proved  that  lesions  of  certain  portions  of  the  nervous  system 
may  suddenly  produce  various  disturbances  in  the  urinary  secretions,  it  is 
not  impossible  that  albuminuria  may  not  be  the  cause  of  eclampsia,  but 
the  result  of  the  same  lesion  which  causes  the  nervous  aflections." 

Hamon  has  shown  albuminuria  to  be  a  neurosis  of  the  central  nervous 
system,  cerebro-spinal  and  ganglionic.  Tessier,  to  the  renal  alterations 
and  to  those  of  albuminuria  of  the  blood,  adds  the  influence  of  the  central 
nervous  system  or  the  nerves  which  preside  over  the  urinary  secretion. 
But  as  Hypolitte  rightly  observes,  the  neuroses  are  of  all  affections  those 
■which  are  most  rarely  accompanied  by  albuminuria.  This  fact  is  particu- 
larly true  of  epilepsy,  the  most  serious  of  all;  and  Hypolitte,  who  tries  to 
explain  these  facts,  supposes  as  an  hypothesis,  that  eclampsia  might  lead 
to  albuminuria,  "first,  from  the  nervous  troubles  which  are  of  the  same  es- 
sence as  it  is  by  acting  directly  on  the  kidneys,  then  by  the  blood  changes 
and  the  pseudo-asphyxia  which  immediately  results,  by  preventing  the 
intra-capillary  combustion  from  taking  place." 

This  opinion  is  not  sustained  to-day,  and  Depaul,  not  considering  it 
too  radical,  hastens  to  add:  ''  If  albuminuria  does  not  certainly  lead  to 
eclampsia,  I  do  not  believe  either  in  the  necessary  production  of  albumi- 
nuria by  eclampsia,  but  I  consider  these  two  symptoms,  as  dependent 
upon  the  changes  which  pregnancy  produces  in  the  composition  of  the 
blood." 

Let  us  add,  finally,  that  if  albuminuria  may  be  wanting  in  eclampsia, 
it  is  the  same  in  anasarca  and  in  oedema,  and  that  in  a  still  greater  pro- 
portion. Thus  the  absence  of  oedema  has  been  noted:  In  27  cases,  by 
Blot  13  times;  in  62,  by  Wieger  10;  in  44,  by  Braiin  9;  in  133,  by  Depaul  14. 

One  can  not  be  certain,  therefore,  from  the  absence  of  oedema,  of  the 
absence  of  albuminuria;  and  the  necessity  of  examining  the  urine  of  all 
pregnant  women  cannot  be  too  much  insisted  on. 

There  remains,  then,  the  last  theory: 

5tli.  Eclampsia  depends  v^Mn  a  poisoning  of  the  Blood,  wliicli  renders 
this  Fluid  unfit  to  stimulate  regularly  the  Nervous  Centres. — What  is  the 
toxic  principle  ?  Is  it  urea  ?  Is  it  the  transformation  of  this  urea  into  car- 
bonate of  ammonia  ?  Is  it  the  extractive  or  coloring  materials  of  the 
blood  ?  Each  of  these  theories  have  been  sustained,  and  thence  the  three 
theories  of  uraemia,  of  amnion jemia,  and  urinsemia. 

1.  Urmmia — Although  Rostock,  Christison  and  G-regory,  first  described 


104  A    TREATISE    ON    OBSTETRICS. 

the  presence  of  an  excess  of  urea  in  the  blood  of  eclamptic  patients,  it 
was  Wilson  who,  in  1833,  created  the  word,  and  the  morbid  entity, 
ursemia.  (Hypolitte.)  Adopted  since  by  all  authors,  this  word  has  re- 
mained in  science,  but  if  the  word  has  remained,  lu  is  not  so  with  the 
theory,  which  attributes  the  cerebral  phenomena  to  the  presence  of  an 
excess  of  urea  in  the  blood.  While  Wilson,  Hammond,  Treifcz,  Lalesky, 
consider  urea  as  poisonous,  Babington,  Bright,  0.  Kees,  Christison,  Fre- 
richs,  Schottin,  Segalas,  Hoppe,  Gallois,  Brown-Sequard,  CI.  Bernard, 
Oppolzer,  prove  that  urea  is  inoffensive,  and  the  theory  of  Wilson  was 
overthrown  by  the  experiments  of  01.  Bernard,  who,  injecting  urea  into 
the  veins  without  producing  convulsions,  proved  that  urea  is  incapable  of 
producing  the  nervous  complications  of  albuminuria  and  eclampsia. 
The  fact,  itself,  of  the  excess  of  urea  in  the  blood  during  the  eclamptic 
attacks,  has  been  confirmed  by  the  analyses  of  Devilliers  a  ad  Eegnault, 
Wurtz  and  Berthelot,  Gubler,  Ritter,  Parkers,  Schottin,  Hosier,  etc. 
Moreover,  recent  researches  in  regard  to  the  temperature  in  eclampsia,  en- 
tirely overthrows  the  theory  of  ursemia,  because  the  temperature  in 
ursemia  is  lowered  gradually  and  considerably,  while  in  eclampsia,  on.  the 
contrary,  it  continues  to  rise.  Let  us  add,  finally,  that  in  cholera,  when 
an  enormous  quantity  of  urea  is  found  in  the  blood,  eclamptic  convulsions 
are  not  observed. 

2.  AmvnoncBmia. — Impressed  by  the  impossibility  of  explaining  these 
complications  by  ursemia,  Frerichs  proposed  the  following  theory:  It  is 
not  urea  by  itself  which  leads  to  these  complications,  but  they  are  due  to 
the  fact  that  urea,  accumulating  in  the  blood,  is  transformed,  by  a  fer- 
ment, into  carbonate  of  ammonia.  It  is  to  this  carbonate  of  ammonia 
that  the  nervous  complications  are  due.  According  to  Mercier,  it  is  not 
carbonate  of  ammonia,  but  urate  of  ammonia,  which  is  the  toxic  agent. 
Finally,  Treitz  returned  to  the  theory  of  carbonate  of  ammonia,  but  it 
is  no  longer,  according  to  him,  in  the  blood  that  the  change  of  urea  into 
carbonate  of  ammonia  is  made.  "  Whenever  the  urinary  secretion  is  sup- 
pressed, the  excretory  matter,  especially  urea,  accumulates  in  the  blood. 
Now  this  urea  passes  from  the  blood  into  all  the  secretions  of  the  econ- 
omy, but  it  is,  above  all,  the  intestinal  mucous  membrane  which  eliminates 
the  greatest  quantity  of  urea.  Poured  into  the  digestive  tube,  the  urea 
is  changed  into  carbonate  of  ammonia,  and  produces  many  lesions.  At 
this  time  the  ammoniacal  salt  has  been  reabsorbed,  and  it  passes  into  the 
blood,  and  the  more  surely  as  the  important  function  of  the  intestinal 
mucous  membrane  is  exactly  the  absorption  of  the  liquids  which  bathe  it. 
It  is  the  reabsorption  of  this  ammonia  contained  in  the  intestine  which 
produces  ammoniacal  intoxication  or  ammonaemia.  This  theory,  upheld 
by  Christison,  Jaksh,  Brettet  Bird,  Oppolzer,  Wieger,  Braun,  has  been 
attacked  by  Richardson,  Picard,  Lalesky,  and  overthrown  finally  by  CI. 
Bernard,  who  has  shown  "  that  the  blood  of  a  well  or  sick  person  contains 


DISEASES    OF   PREGNAITCY.  105 

almost  always  carbonate  of  ammonia;  and  that,  if  urea  is  found  in  the  in- 
testinal fluid  as  an  ammonia  salt,  and  not  as  urea,  it  is  only  because  when 
this  substance  appears  in  the  intestinal  canal,  it  dissolves  in  the  fluids,  in 
the  midst  of  which  fermentation  goes  on,  which  continually  destroys  the 
ammoniacal  salts,  as  soon  as  they  are  found." 

3d.  UrbicmiiLa. — Schottin  has  declared  that  the  kidneys  secrete  not  only 
urea,  but  other  substances  stil'l  little  known,  (creatin,  creatinin,  leucine, 
etc.),  a*id  designated  under  the  vague  name  of  extractive  materials;  these 
accompany  urea,  remain  in  the  blood,  and  produce  blood  poisoning,  and 
consequently  convulsions.  This  theory,  upheld  by  Keuling,  Hoppe,  Op- 
pler.  Perls,  Lalesky,  Fabius,  Fournier,  Chalvet  and  Gubler,  has  received 
from  the  latter  authors  the  name  of  urina^mia,  by  which  it  is  known  to- 
day. The  experiments  of  Challan,  1865,  have  confirmed  it,  and  it  is  ac- 
cepted by  Peter. 

"  The  pregnant  woman,  affected  by  eclampsia,  is  urinaBmic.  It  is  be- 
cause all  the  elements  of  the  urine  have  accumulated  in  her  blood,  that 
she  is  a  prey  to  the  complication  known  as  eclampsia.  There  occurs  a 
great  and  complex  disturbance  of  innervation,  of  which  convulsions  are 
only  a  symptom.  There  may  be  convulsions,  coma  or  delirium,  but 
always  with  a  predominance  of  convulsions,  and  it  seems  best  to  designate 
the  combination  of  symptom-S  by  the  term  '  puerperal  urinsemia. '  The 
analysis  of  the  urine  shows,  without  a  doubt,  that  the  woman  excretes 
daily  a  greater  quantity  of  urea.  Quinquaud  has  shown  that  during  preg- 
nancy, and  on  its  account,  a  woman  excretes  daily  one  and  a  half  times 
more  urea  than  in  the  non-pregnant  condition.  If  she  excretes  twice  as 
much  urea  in  twenty-four  hours,  she  ought  to  do  more  work — i.e.,  more 
blood  passes  through  the  kidney,  and  there  is  an  increased  functional  hy- 
per^emia.  As  a  result  of  more  blood,  there  is  greater  pressure;  if  greater 
vascular  pressure  exists,  then  possible  filtration  of  the  serum  of  the 
blood,  nay  even  the  blood  itself — a  phenomenon  which  is  called  incorrectly 
albuminuria,  but  it  is  serumuria."  Now  how  does  this  serumuria, 
physiological  when  it  is  of  slight  amount,  becoming  greatly  increased,  ir- 
ritate, poison  the  organism,  and  cause  eclampsic  attacks  ? 

One  can,  by  the  aid  of  the  examination  of  the  urine,  judge  of  the  state 
of  the  kidney.  The  more  serum  there  is,  the  more  the  kidney  is  inert, 
so  that  the  integrity  of  the  kidney  is  in  inverse  proportion  to  the  amount 
of  albumin  contained  in  the  urine.  With  the  microscope,  the  exact  state 
of  the  kidney  can  be  made  out,  by  means  of  the  presence  of  casts,  granular 
and  hyaline.  These  latter  show  that,  at  certain  points,  where  this  des- 
quamation has  taken  place,  the  kidney  is  totally  useless,  so  far  as  secre- 
tion of  urine  is  concerned.  It  is  only  a  passive  organ,  through  which  the 
serum  filters,  as  it  would  through  a  filter  paper.  It  is  necessary,  there- 
fore, to  look  for  serum  in  the  urine;  if  it  exists  there,  to  examine  the  state 
of  the  nervous  system  for  premonitory  signs  of  eclampsia.     There  is  not 


106 


A   TREATISE    OIST    OBSTETRICS. 


IDresent  as  yet  eclamj^sia,  but  only  a  tendency  toward  urinsemia.  There 
is  not  only  an  accumulation  of  urea,  but  the  accumulation  of  all  the 
constituents  of  the  urine. 

Very  exact  analysis  of  the  urine  shows  an  accumulation  of  all  the  ma- 
terials of  the  urine  in  the  blood  of  a  woman  inclined  towards  uringemia. 
In  a  first  observation,  in  place  of  6  parts  of  extractive  matters  in  15,000 
grains  of  urine,  Quinquaud  found  31  parts,  i.e.,  3-|-  times  more^,urea  in 
the  blood.  These  figures  agree  exactly  with  a  second  observation  which 
gives  19.2  in  place  of  6  parts;  a  third  gives  18.3.  This  makes  three  times 
more  extractive  material.  I  do  not  know  of  anything  more  convincing, 
and  we  need  not  say  that  it  is  only  creatinasmia  (Schottin  and  Hoppe),  but 
all  the  urinary  extractives  are  present,  that  is  to  say,  urinamia.  The 
pregnant  woman  no  longer  forms  urine,  no  longer  selects  decomposed  ele- 
ments which  are  the  urine;  they  remain  and  accumulate  in  the  blood, 
and  therefore  she  is  diseased. 

Contrary  to  Quinquaud,  Hypolitte  has  not  found  urea  increased  in  the 
blood  of  pregnant  women,  but  diminished;  and  finally  he  says,  that  in  cer- 
tain patients  suffering  from  oligemia  or  anuria,  as  in  cases  of  hysteria,  or 
of  retroversion  of  the  gravid  uterus,  accompanied  by  compression  of  the 
bladder  and  oligemia,  eclampsia  is  not  observed. 

Hypohtte  gives  in  the  following  table  the  examination  of  the  urine  of 
eclamptic  women: 


Eclampsia. 

Temperature 
Axilla. 

Volume 

of 
Urine. 

Urea. 

Album.in. 

Process  of 
Yvon. 

Process  of 
Liebig. 

28  days  before  labor 
During  labor  and  during 
an  eclamptic  attack 

Eclampsia  during  labor 

98.4°  evening. 
102."  morning. 

Ounces. 

27 

15 

47 

Grains. 
108 

48 
375 

Grains. 

180 

Albumin. 

14  grains. 
Marked  trace. 

From  this  table  it  results  that  urea  is  rather  diminished  than  increased 
during  pregnancy,  and  that  it  varies  with  the  process  employed.  Thus 
between  Yvon's  and  Liebig's  methods,  there  may  be  a  difference,  varying 
between  15  to  75  grains.  What  do  all  these  theories  prove  ?  which  is  true  ? 
It  is  at  the  present  time  impossible  to  say. 

It  cannot  be  doubted,  says  Fournier,  *'  that  it  seems  rational  to  attri- 
bute these  phenomena,  obsarved  during  life,  to  an  alteration  in  the  blood. 
I'liis  alteration  is  not  doubted;  it  does  not  consist  in  the  retention  of  one 
principle  alone,  but  the  alteration  is  still  poorly  understood." 

Lately,  practical  researches  in  regard  to  the  temperature  in  eclampsia, 
have  shown  thttt  all  these  theories  are  useless.  It  was  in  France  that  the  first 
authentic  researches  on  the  temperature  in  eclampsia  were  published,  and 
Winckel  is  in  error  when,  with  the  fairness  and  fidelity  which  charac- 


DISEASES    OF    PREGNANCY.  107 

terizes  the  Germans,  lie  tries  to  appropriate  the  credit  of  tliis  discovery, 
(but  tiiis  does  not  surprise  us).  "  The  French  authors/'  says  Winckel, 
"naturally  do  not  recognize  my  works."  This  important  work  confines 
itself  to  the  following  phrase,  which  is  found  in  the  "Clinical  observations 
on  the  Pathology  of  Labor,"  1869,  liostock,  which  he  has  reproduced  in 
his  second  edition.  "  The  temperature  rises  very  considerably  at  each 
new  attack.  It  may  go  as  high  as  104.5°  F."  From  1874  to  1875  and 
1876,  in  these  observations  and  studies,  he  published  various  observations 
on  eclampsia,  in  which  he  notes  the  temperature  before  the  attack,  but 
not  during,  and  he  takes  it  again  only  after  two  days,  to  find  that  it  has 
risen  to  105°  F.,  under  the  influence  of  a  new  disease.  It  was  only  tben 
in  1879,  i.e.,  when  he  must  have  known  of  the  French  works  for  a  long 
time,  that  he  really  began  the  study  of  the  subject.  This  does  not  sur- 
prise us,  for  this  appi'opriative  method  does  not  confine  itself  to  scien- 
tific subjects. 

It  was  in  France,  in  the  Faculty  at  Strasburg,  that  the  first  observations 
on  the  tempei'ature  in  convulsions  were  made.  It  is  to  Kien,  a  pupil  of 
Hirtz,  that  they  are  due.  For,  although  Q.uincque  had,  in  Germany, 
in  1869,  taken  the  temperature  in  eclampsia  in  a  careful  manner,  he  had 
drawn  no  conclusions,  and  confined  himself  to  a  simple  statement;  and 
the  proof  of  this  is,  that  Wunderlich,  whose  work  appeared  in  1871,  col- 
lected all  the  thermometric  observations  acquired  in  medicine,  and  left 
aside  entirely  the  course  of  the  temperature  in  puerperal  eclampsia. 

In  1869,  at  the  suggestion  of  Charcot,  his  teacher,  Bourneville  under- 
took the  study  of  the  course  of  the  temperature  in  diseases  of  the  nervous 
system,  and  in  1871  to  1875,  pursuing  these  studies,  he  arrived  at  the  fol- 
lowing conclusions,  based  on  13  personal  observations  and  4  of  Budin's. 

1st.  In  eclampsia,  the  temperature  rises  from  the  beginning  to  the  end 
of  the  attack. 

2d.  In  the  interval,  the  temperature  remains  high,  and,  at  the  time  of  a 
convulsion,  there  is  a  slight  rise. 

3d.  If  the  eclampsia  is  going  to  prove  fatal,  the  temperature  continues 
to  increase  and  may  be  very  high.  If,  on  the  contrary,  the  attacks  dis- 
appear, and  if  the  coma  lessens  or  ceases  altogether,  the  temperature  falls 
gradually,  and  may  become  normal. 

4th.  Finally,  Bourneville,  concerning  the  diagnosis  between  puerperal 
eclampsia  and  uraemia,  adds:  "  Most  authors  class  under  the  term  Ura3mia 
both  eclampsia  and  various  forms  of  uraemia.  ISTowof  31  cases  of  true 
uraemia  which  we  have  observed  in  men  and  in  women,  whether  caused 
by  an  affection  of  the  kidneys,  or  an  obliteration  of  the  ureters,  (calculi, 
cancer,  etc.),  whether  it  be  in  the  form  of  coma  or  convulsions,  the  tem- 
perature gradually  falls,  and  at  times  below  93°  F." 

Hence  a  very  striking  contrast  between  the  thermometric  curve  of  puer- 
peral eclampsia  and  that  of  uraemia,  which  we  will  sum  up  in  the  follow- 


108  A   TREATISE    ON   OBSTETRICS. 

ing  statement:  In  the  beginning,  a  lowering  of  the  temperature  in 
uraeniia  is  noticed,  and  an  elevation  of  the  temperature  in  puerperal 
eclampsia.  In  the  course  of  uremia,  the  temperature  falls  gradually, 
while  in  that  of  eclampsia  it  rises  more  and  more,  from  the  beginning  of 
the  attack,  usually  very  suddenly.  These  differences  are  greater  at  the 
approach  of  and  even  at  death.  In  uriemia  the  temperature  falls  very 
much  below  the  normal;  in  puerperal  eclampsia,  on  the  contrary,  it  rises 
very  high  above  the  normal. 

Pinard  and  Bud  in  liav^;  published  a  great  many  thermometric  observa- 
tions of  eclampsia.  Also  Dieude  and  Herbart  have  written  on  the  subject 
(1875),  also  BuJfet  (1877),  Lorain  (1877),  Deubel  (Kancy,  1879)  and 
lastly  Hypolitte  (1880.) 

In  1879  only,  does  Winckel  report  four  cases  of  eclampsia,  and 
reach  the  following  conclusions:  ''The  most  striking  thing  is  the  un- 
usual course  of  the  temperature,  which,  during  sixteen  hours  without 
attacks,  rose  from  normal  to  102.4°,  which,  a  little  before  the  third  attack, 
had  fallen  to  100.4°,  and  rose  again  at  the  beginning  of  the  sixth  attack 
to  102.3°,  bvit  fell,  finally,  from  1°  to  5°  until  death,  although  during  this 
short  space  of  time  the  patient  had  still  attacks  of  eclampsia.^' 

Dieude,  from  his  observations,  concludes  that:  "  The  first  statement 
of  Bourneville  is  too  absolute,  and  that  in  eclampsia,  not  only  does  the 
temperature  not  rise  continually,  from  the  beginning  to  the  qnd,  but  it 
may,  rarely  it  is  true,  remain  stationary  or  fall  in  spite  of  the  attacks; 
but  he  is  in  accord  with  him  in  this,  that,  whenever  the  temperature, 
after  having  followed  the  ordinary  course  peculiar  to  puerperal  eclampsia, 
falls  gradually,  a  favorable  termination  can  be  prognosticated.^^ 

Deubel  similarly  considers  the  statements  of  Bourneville  as  too  abso- 
lute. 

Finally,  Hypolitte,  who  bases  his  researches  on  thirty  observations,  has 
arrived  at  the  following  conclusions,  which  are  those  of  Dieude  slightly 
modified. 

"1st.  In  the  great  majority  of  cases,  the  temperature  rises  from  the  be- 
ginning to  the  end  of  the  attack,  but  it  may,  though  rarely,  remain  sta- 
tionary or  fall  in  spite  of  the  attack.  The  temperature  rises  most  often 
to  the  highest  point  during  the  tonic  convulsion,  to  fall  slightly — two- 
tenths  to  three-tenths  of  a  degree,  during  the  clonic  -convulsion.  2d. 
Betwe.en  the  attacks,  the  temperature  remains  high,  and,  on  the  return  of 
a  spasm,  the  temperature  rises.  After  several  attacks,  the  temperature 
may  remain  normal  or  subnormal  or  over  1°,  but  the  temperature  does 
not  remain  there  with  subsequent  attacks,  or  in  the  interval  between  the 
attacks,  the  temperature  reaches  the  high  point  which  is  usually  observed. 
3d.  If  the  eclampsia  is  to  end  in  death,  the  temperature  continues  to  in- 
crease, and  rises  very  high;  if,  on  the  contrary,  the  attacks  disappear, 
and  if  the  coana  diminishes,  or   ceases  altogether,  the  temperature  falls 


DISEASES    OF   PREGNANCY.  109 

^nuiuaiiv  and  becomes  normal.  It  may  happen,  also,  that  the  tempera- 
ture begins  to  fall  before  the  end  of  the  attack.  4th.  In  eclampsia,  the 
temperature  remains  usually  between  100.4°  and  104°,  and  may  go  above 
105.4°  after  death,  and  even  reach  10G°  to  107°  and  over.  The  pulse 
follows  the  course  of  the  temperature  exactly,  100  to  140,  and  at  times 
ICO." 

As  we  will  see,  these  thermometric  researches  have  a  great  importance 
from  a  diagnostic  and  prognostic  standpoint. 

Symptoms. — Although  eclampsia  sometimes  developes  suddenly  and 
sharply,  surprising  the  patient  as  an  epileptic  attack, this  is  not  the  rule,and, 
most  commonly,  the  attacks  come  on  after  a  prodromic  stage,  but  the  pro- 
dromata  themselves  present  certain  differences,  occasionally  being  faint,  at 
other  times  they  come  on  just  before  the  attack.  They  are  cephalalgia, 
disturbances  of  vision,  epigastric  pain,  dyspnoea,  vomiting,  insomnia,  ver- 
tigo and  excitement. 

Among  the  slight  prodromata  must  be  noted  insomnia,  or,  on  the  con- 
trary, deep  sleep,  excitement,  vertigo;  the  latter  may  be  accompanied  with 
a  dullness  of  the  intellect,  more  or  less  marked.  The  patient  seems  sim- 
ply to  exist,  scarcely  interesting  herself  in  things  about  her,  answering 
questions  more  or  less  correctly.  She  seems  to  live  in  a  sort  of  trance,  a 
physical  and  moral  apathy.  She  complains  of  vertigo,  transient  dimness 
of  vision,  and,  above  all,  of  head-ache  more  or  less  severe,  situated  gener- 
ally in  the  back  part  of  the  head,  rarely  in  the  occiput,  sometimes  in  the 
temporal  region.  This  head-ache,  which  is  at  first  transient,  and  appears 
only  occasionally,  becomes  day  by  day  more  persistent,  more  fixed,  more 
intense,  and  finally  continuous,  and  when  the  attack  is  near  at  hand  the 
head-ache  becomes  so  intense  as  to  be  unbearable.  Then  vomiting  appears, 
which  may  be  bilious  or  stercoraceous,  and  may  reappear  suddenly  in 
some  women  who  have  been  free  from  it  for  some  time. 

Next  appear  the  prodromata  which  indicate  that  the  attack  is  immi- 
nent, i.e.,  disturbances  of  vision,  epigastric  pain  with  or  without  dyspnoea. 
The  disturbances  of  vision,  although  being  an  indication  of  an  impending 
attack,  may  come  on  beforehand,  but  then,  usually,  they  are  not  well 
marked.  They  accompany  then  the  head-ache,  and  are  confined  to  a  little 
disturbance  of  sight,  and  fatigue,  which  prevent  the  patient  from  read- 
ing or  amusing  herself.  But  when  they  come  Just  before  the  attack,  they 
are  more  marked,  and  the  disturbances  of  vision  are  observed,  i.e.,  am- 
blyopia, diplopia,  and  even  complete  blindness.  At  the  same  time,  the 
head-ache  becomes  more  marked,  and  the  patient  goes  into  a  state  of  pro- 
found stupor,  which  had  been  slight  up  to  this  time.  To  the  disturbances 
of  vision  are  often  added  a  sharp  epigastric  pain,  sometimes  so  violent 
that  the  patient  cries  out.  This  pain,  this  epigastric  oppression,  may 
accompany  dyspnoea,  although  this  sometimes  precedes  the  epigastric  pain. 

Epigastric  pain,   disturbances  of  vision  and  dyspnoea,  are  the  three 


110  A   TREATISE    ON    OBSTETEICS. 

symptoms  which  announce  the  onset  of  eclampsia,  and  which  may  pre- 
cede it  by  a  few  hours,  but  sometimes  come  on  only  a  few  minutes  before 
the  attack. 

In  spite  of  the  disturbances  of  vision,  the  ocular  media  remain  trans- 
parent, excepting  a  little  congestion  of  the  ocular  conjunctiva,  on  a  level 
Avith  the  oculo-palpebral  fold,  but  it  is  only  after  an  attack  that  we  find 
retinal  lesions,  hemorrhages  and  congestion,  which  often,  however,  may 
be  wanting. 

Wieger  claims  that  the  frequency  of  the  prodromata  is  not  the  same, 
according  as  the  eclampsia  occurs  before,  during  or  after  confinement. 
Eclampsia  of  pregnancy  will  have  prodromata  in  40  per  cent,  of  the  cases; 
that  of  labor  in  30  per  cent.,  and  that  of  the  puerperal  state  in  20  per  cent. 

Attacks  of  eclampsia  are  not  all  alike,  and  if,  in  most  cases,  the  move- 
ments are  not  increased,  and  do  not  require  a  great  amount  of  power  to 
restrain  the  patient,  at  other  times,  on  the  other  hand,  the  patient  is 
greatly  excited,  so  that  we  can,  with  difficulty,  prevent  her  from  falling 
or  throwing  herself  out  of  bed. 

The  attack  finally  comes  on  and  may  be  divided  into  three  periods: 
1.  The  period  of  invasion;  2.  The  period  of  tonic  convulsions;  3.  The 
period  of  clonic  convulsions. 

1.  The  Period  of  Invasion. — All  at  once  the  eyes  become  fixed,  there 
follows  a  moment  of  quiet,  and  the  attack  begins  by  convulsive  movements 
of  the  face,  which  is  contracted  in  a  thousand  ways  and  makes  horrible 
contortions.  The  eyelids  fall  and  rise  through  rapid  twitchings,  and  the 
eyes,  drawn  by  the  convulsive  movement  of  their  muscles,  roll  in  their 
orbits,  drawn  sometimes  one  Avay,  sometimes  another.  The  pupil  is  dilated, 
immovable,  insensible  to  light,  the  ocular  conjunctiva  is  insensible  to 
stimulation  and  to  light,  and  finally  the  eye,  drawn  upward  by  the  levator 
muscles,  partly  disappears  behind  the  upper  lid,  leaving  in  view  only  the 
lower  segment  of  the  sclerotic,  and  a  very  small  part  of  the  pupil.  It 
lastly  remains  fixed  on  that  side  of  the  orbit  toAvard  which  the  commissure 
of  the  lips  is  drawn.  These  are  not  sIoav  in  taking  part  in  the  convul- 
sions; the  mouth,  more  or  less  distorted,  deviates  strongly  to  the  left  side, 
as  a  rule,  and  the  head  being  rotated,  the  face  to  the  left  side  rotates 
back  again  to  the  right  shoulder,  and  finally,  it  is  directed  to  the  left;  the 
alae  of  the  nose,  strongly  pinched  and  contracted,  draw  down,  and 
towards  the  lower  part  of  the  nostrils. 

2.  Period  of  Tonic  Convulsions. — From  the  head,  the  convulsions 
extend  to  the  muscles  of  the  neck,  of  the  body,  and  the  limbs,  which  are 
greatly  contracted.  The  extensor  muscles  of  the  neck  and  trunk  produce 
a  curve  of  the  spine,  with  the  concavity  turned  backward,  and  the  patient, 
raised  up  by  the  contraction,  only  rests  on  the  bed  by  the  head  and  lower 
limbs,  in  a  true  state  of  opisthotonos,  the  Avhole  body  being  rigid.  At 
the  same  time,  the  arms  are  stretched  and  rigid,  undergoing  a  marked 


DISEASES    OF    PREGNANCY.  1  1  1 

movement  of  pronation,  while  the  fists  are  closed,  and  the  thumbs  turned 
into  the  palm  of  the  hands,  which  cannot  be  opened.  The  diaphragm, 
the  muscles  of  the  thorax,  take  their  turn.  Eespiratiou  is  suspended, 
and  the  face,  instead  of  the  livid  pallor  which  it  has  presented,  becomes 
red,  sAvoUen  and  tumefied,  as  in  asphyxia.  At  the  same  time,  the  mus- 
cles at  the  base  of  the  tongue  contract,  the  tongue  projects  out  of  the 
half  open  mouth,  the  jaAvs  rise  and  fall  spasmodically;  the  tongue  is 
bitten  and  cut  by  the  teeth,  and  the  blood  mixing  with  the  saliva,  forms 
a  bloody  froth  Avhich  dribbles  out  of  the  mouth.  The  muscles  of  the 
larnyx,  throat,  pharynx,  contract  violently,  and  when  respiration  becomes 
re-established,  it  is  noisy  and  whistling.  At  the  same  time,  there  is 
absolute  loss  of  sensibility  and  intelligence,  so  that  the  patient  may  be 
pinched  and  pricked  without  being  conscious  of  it. 

Such  is  the  ordinary  aspect  of  the  eclamptic,  during  the  tonic  period, 
which  is  thus  characterized  by  rigidity,  immobility,  and  insensibility  of 
the  patient,  with  impeded  respiration,  all  coming  on  suddenly  and  unex- 
pectedly. It  is  not  always  so,  however,  and  with  many  patients,  as  Bailly 
has  shown,  the  attack  is  preceded  by  a  very  short  period  of  excitement, 
during  which  the  patient,  instead  of  stretching  her  arms  along  her  body, 
raises  them  over  her  face,  as  if  she  wished  to  defend  herself  from  an  im- 
aginary enemy.  The  tonic  contractions  come  on  secondarily.  This  ex- 
aggerated tonic  state  of  the  muscles  lasts  generally  for  fifteen  to  twenty 
seconds,  and  then  begins  the  third  period  of  clonic  convulsions. 

Third  Period. — This  general  muscular  rigidity  is  followed  by  shakings 
and  twitchings,  which  agitate  incessantly,  arid  in  turn,  all  the  muscles  of 
the  face,  body  and  limbs.  As  in  the  tonic  convulsioiis,  it  is  in  the  face 
that  they  begin,  to  reach  finally  the  body  and  limbs.  The  face,  also,  is 
horribly  disfigured,  the  jaws  open  and  shut,  cutting  the  tongue,  which 
bleeds  more  and  more,  swells,  and  thus  contributes  to  increase  the  hin- 
drance to  respiration.  It  is,  indeed,  in  the  clonic  convulsions,  that  respi- 
ration, suspended  during  tonic  convulsions,  reappears,  but  it  is  irregular, 
noisy  and  whistling,  and  is  accompanied,  at  each  expiration,  by  expulsion 
of  a  froth  more  or  less  bloody,  sometimes  even,  when  the  tongue  is  very 
much  cut,  by  almost  pure  blood.  Generally,  the  shaking  of  the  body  and 
limbs  makes  itself  apparent  by  slight  twitchings,  which  pass  off,  and  occur 
without  the  patients  changing  much  in  position.  This  is  not  always  so, 
however,  and  in  certain  cases,  as  soon  as  the  clonic  convulsion  comes  on, 
they  are  very  much  excited,  throw  themselves  from  right  to  left,  so  that 
it  is  difficult  at  times  to  hold  or  restrain  them.  During  this  period,  the 
cutaneous  and  visceral  congestion  increases,  and  the  face  is  blue,  red,  livid, 
seems  as  swollen  as  that  of  a  drowned  person  who  has  been  long  in  the 
water.  Sub-conjunctival  hemorrhages  take  place,  and,  on  account  of 
contractions  of  the  diaphragm,  or  the  muscles  of  the  abdomen,  as  Jacque- 
mier,  Depaul  and  Bailly  believe,  or  even  on  account  of  intestinal  contrac- 


112  A    TREATISE    ON    OBSTETRICS. 

tions,  as  Lacliapelle  and  Tyler  Smith  and  we  are  disposed  to  believe,  ab- 
dominal evacuations  frequently  occur.  Evacuations  of  urine  are  nor  very 
frequent,  owing  to  tlie  small  amount  of  urine  in  the  bladder  of  eclamptic 
patieiits.  Vomiting  is  rare,  and  we  have  seen  it  generally  in  patients 
,who  have  inhaled  chloroform. 

This  period  of  clonic  revulsions  is  longer  than  the  tonic  period,  but 
we  have  not  seen  it  extend  over  one  or  two  minutes.  Bailly,  who  has 
given  one  to  five  minutes  as  the  limit,  appears  to  go  too  far;  likewise, 
Tarnier,  avIio  has  seen  the  attack  prolonged  twenty  minutes  by  the  watch. 
Ordinarily  we  would  yield  to  the  testimony  of  such  a  conscientious  and 
careful  observer  as  Tarnier,  but  we  believe  that  he  has  taken  the  case  of 
a  woman  in  whom  the  attacks  followed  each  other  so  quickly  that  there 
was  no  intermission,  and  therefore  the  limit  we  have  fixed  upon  for  the 
duration  of  the  attacks  seems  to  be  the  rule. 

If  we  consider  the  congested  and  asphyxiated  condition  of  the  patient 
during  a  tonic  and  clonic  convulsion,  we  can  not  understand  how,  when 
respiration  is  so  impeded,  the  patient  could  long  survive  such  a  condition 
of  things. 

While  the  limbs  and  body  are  so  shaken  by  convulsive  twitchings,  the 
face,  which  was  drawn  to  one  side,  returns  to  the  middle  line,  but  is  still 
carried  from  one  side  to  another  by  muscular  twitchings.  The  twitching 
of  the  eyelids  is  still  present,  and  also  the  movement  of  the  eyes.  Kes- 
]3iration,  for  a  while  suspended,  returns,  but  accelerated,  and  becomes 
more  and  more  blowing  and  whistling.  It  is  irregular,  the  muscles  of  in- 
spiration and  expiration  taking  part  in  the  clonic  convulsion  which  in- 
volves the  whole  system. 

Tyler  Smith  states  that  the  muscles  of  the  larynx  share  in  this  spas- 
modic contraction,  and  it  is  the  closure  of  the  glottis  that  is  the  cause 
of  the  bruit  produced  in  respiration.  Asphyxia  is  the  consequence  of 
the  suspension  or  diminution  of  the  blood-producing  process.  Hence 
the  bluish-black  discoloration  of  the  face,  the  swelling  of  the  neck  and 
face,  the  enlargement  of  the  jugulars,  and  the  violent  beating  of  the 
carotids.  He  thinks  also  that  the  heart  participates  in  the  convulsion, 
and  this  would  explain  why  the  lividity  and  turgescence  is  not  always 
limited  to  the  face,  but  may  extend  sometimes  all  over  the  body. 

At  the  beginning  of  the  attack,  Cazeaux  says,  the  pulse  is  full  and 
strong,  but  we  have,  on  the  contrary,  seen  it  always  rapid  and  feeble,  so 
feeble  that  it  is  sometimes  difficult  to  count  it;  but,  remarkable  enough, 
however  feeble,  we  have  always  seen  it  increase  in  cases  in  which  vene- 
section has  been  practised,  as  in  DepauFs  clinic. 

When  the  end  of  the  attack  approaches,  the  skin,  which  was  dry,  be- 
comes covered  with  perspiration  more  or  less  abundant,  the  respirations 
become  a  little  longer,  more  regular,  the  convulsions  diminish  in  violence 
and  frequency,  first  in  the  body  and  limbs,  then  in  the  face,  the  livid  ap- 


DISEASES    OF    PKEaNANCY.  113 

pearance  disappears  gradually,  lastly  in  the  face,  where  it  may  remain  for 
some  time.  The  attaek  ends  generally  with  a  deep  inspiration,  followed 
by  a  slow  and  prolonged  expiration.  The  patient  sinks  back  in  bed  in  a 
state  of  coma  or  stupor  more  or  less  pronounced.  Whether  there  be  one 
eclampsic  attack  or  several,  never  does  the  patient  regain  her  normal 
condition  immediately  after  the  attack,  but  she  remains,  for  a  given  length 
of  time,  in  a  comatose  state,  with  loss  of  intelligence  and  sensibility.  But 
it  is  understood  that  this  condition  or  state  is  less  pronounced  and  long 
as  the  attacks  are  less  violent,  or  as  they  have  been  few  in  number,  and, 
iinally,  the  further  apart  the  attacks  have  been. 

Generally,  after  the  first  attack,  coma  and  stupor  do  not  persist  a  long 
time.  In  a  few  minutes  the  breathhig,  which  was  noisy,  becomes  calm 
and  regular.  The  patient,  quiet  and  motionless,  moves  frequently  in  bed, 
opens  her  eyes,  looks  vaguely  about  her,  without  knowing  where  she  is, 
or  why  she  is  kept  there,  nor  does  she  recognize  those  about  her.  Little 
by  little  consciousness  returns,  sensibility  reappears,  and,  when  the  pa- 
tient is  spoken  to,  she  tries  to  reply,  and  is  not  able  to  do  so,  on  account 
of  the  mental  disturbance  Avhich  exists,  and  also  on  account  of  difficulty 
of  articulation  caused  by  the  swelling  and  sensibility  of  the  tongue. 
Slowly  consciousness  returns,  but  memory  is  still  at  fault,  so  much  so  that 
the  patient  has  forgotten  her  pregnancy,  her  address  or  her  name,  and 
it  is  only  after  several  hours  that  consciousness  is  more  completely  re- 
stored, but  memory  returns  only  at  the  end  of  twenty-four  to  thirty-six 
hours  or  even  more.  At  times,  it  is  true,  when  there  is  only  one  attack, 
a  normal  condition  is  regained  sooner,  but  this  is  rare,  and  usually  the 
first  attack  is  soon  followed  by  another  or  several.  The  new  attacks  may 
be  separated  by  shorter  or  longer  intervals,  and  then,  in  the  first  instance, 
they  come  upon  the  woman  when  she  is  in  the  coma  following  the  first 
attack;  or,  secondly,  the  woman  may  have  regained  consciousness,  and 
•have  come  out  of  her  comatose  state  befoi'c  the  return  of  convulsions. 
Each  new  attack  is  preceded  by  a  new  period  of  excitement,  and  the  scene 
is  gone  over  again,  with  a  severity  proportionate  to  the  number  of  the  at- 
tacks. As  these  attacks  are  renewed,  the  coma  becomes  more  and  more 
profound,  and,  in  cases  where  they  are  renewed  again  and  again,  the 
patient  passes  from  a  comatose  state  into  new  attacks,  and  vice  versa  to 
the  last. 

But  the  attacks  themselves  vary  in  intensity.  At  times  one  or  two  vio- 
lent attacks  are  followed  by  a  lighter  one,  then  there  follows  a  more  vio- 
lent one.  Sometimes  two  or  three  attacks  follow  each  other  in  quick 
succession,  then  after  an  interval  of  half  an  hour  or  several  hours;  then 
the  attacks  are  renewed  with  greater  frequency  and  intensity.  Sometimes 
the  attacks  come  at  regular  intervals,  five  to  ten  minutes,  every  half  hour, 
or  every  hour;  at  other  times  without  regularity;  at  other  times  still, 
they  are  repeated  with  such  violence  and  intensity  that  they  do  not  in- 
VoL.  II.— 8. 


114  A    TREATISE    ON    OBSTETRICS. 

termit  at  all,  but  are  continuous,  and  we  believe  these  to  be  the  cases, 
cited  by  certain  authors,  in  Avhich  the  attacks  lasted  ten  to  fifteen  min- 
utes, as  in  Tarnier's  case.  The  tonic  period  is  obscured  by  the  incessant 
clonic  convulsion,  and  this  will  explain  the  error  into  which  these  ob- 
servers have  fallen,  when  they  give  such  a  long  duration  to  an  eclampsic 
attack.  The  coma  is  always  proportionate  to. the  severity  of  the  attack, 
and,  when  they  are  numerous,  the  woman,  if  she  recovers,  is  always  a 
longer  time  in  coming  out  of  the  coma  than  when  the  attacks  are  few  in 
number,  and  the  interval  between  them  long.  On  the  other  hand,  if  the 
attacks  are  long  and  rbpeated,  the  coma  is  profound  and  persistent.  It  is 
often  only  at  the  end  of  twelve,  twenty-four  or  thirty-six  hours  that  the 
patient  becomes  conscious  of  what  is  going  on  about  her. 

The  patient  may  be  roused  from  her  stupor  for  a  moment,  her  eyes 
open,  but  shut  again  at  once,  the  few  words  which  can  be  drawn  from 
her  are  incoherent,  the  movements,  if  any,  are  mechanical,  and  she  soon 
relapses  into  the  comatose  state.  The  memoi'y  is  the  last  to  return,  and 
this  rarely  takes  place  until  three  or  four  days  have  passed,  the  patient 
being  only  partially  conscious  of  what  is  going  on  about  her.  As  for  the 
attacks,  the  patients  are  not  at  all  conscious  of  them,  and  manifest  some 
surprise  at  finding  themselves  in  bed,  and  know  nothing  of  their  confine- 
ment, which,  as  we  shall  see,  may  have  taken  place  during  the  convul- 
sion; and  Avhen  they  find  themselves  in  the  hospital,  they  ask  why  and 
how  they  have  been  brought  there.  When,  on  the  contrary,  they  die, 
the  coma  becomes  more  marked,  the  breathing  becomes  stertorous,  con- 
sciousness and  sensibility  is  entirely  abolished,  and  death  takes  place, 
either  in  a  new  attack  or  before  the  patient  becomes  conscious.  In 
some  cases,  the  coma  is  interrupted  by  a  certain  amount  of  excitement, 
by  cries;  it  would  seem  that  the  patient  was  going  into  another  attack, 
but  this  is  aborted,  and  she  passes  into  a  stupor  which  may  yield  in  its 
turn  or  end  in  death. 

Course  and  Duration. — Eclampsia,  on  account  of  the  rapidity  of  its 
course  and  its  gravity,  should  rank  among  the  acute  diseases.  It  is  rare 
for  it  to  last  more  than  two  days  without  ending  in  a  cure,  or  in  compli- 
cations which  may  lead  to  death;  but  the  course  of  the  disease  may  pre- 
sent numerous  varieties.  First,  the  number  of  the  attacks,  which  in 
some  women  are  limited  to  two  or  three  or  even  one,  may  reach  in  others i 
to  100  (BailJy,  Pajot)  or  IGO  as  Crettet  observed.  The  intervals  between 
the  attacks  are  not  fixed,  and  the  attacks  themselves,  which  are  renewed 
with  a  sort  of  mathematical  regularity,  may,  on  the  other  hand,  be  very 
irregular.  At  times,  several  attacks  occur  one  after  another,  and  a  long 
interval  passes  without  an  attack,  when  they  occur  again  with  renewed 
violence.  In  some  patients  the  attack  appears  over,  when,  at  the  end  of 
twelve,  eighteen,  twenty-four,  forty-eight  hours,  a  new  attack  appears, 
and  this  explains  why  certain  authors  have  described  the  startling  and 


DISEASES    OF    PREGNAlSrCY.  115 

very  sharp  forms,  and  those  relatively  slow.  Paul  Dubois  goes  farther 
when  he  says  that  one  of  the  dangers  of  eclampsia,  once  declared  during 
pregnancy,  is  that  it  will  reappear  until  term.  But  this  must  be  very 
rare,  for  where  eclampsia,  which  occurs  before  term,  ceases  in  a  few  days, 
it  reappears  no  more  even  at  the  time  of  confinement,  or  else,  as  a  rule, 
it  induces  premature  labor.  The  attacks  themselves  present  many 
varieties;  sometimes  few,  with  long  intervals,  or  at  other  times  slight  and 
frequent.  Often  they  have  this  character  during  labor.  The  latter 
ended,  there  is  an  interval  of  repose,  and  the  attacks  are  renewed  with  a 
fatal  result.  At  other  times,  instead  of  beginning  with  the  uterine  con- 
tractions, the  attacks  come  on  before  labor,  cease  when  it  begins;  then 
labor  is  arrested,  the  attacks  come  on  again;  at  other  times  there  is  an. 
attack  at  each  contraction. 

Termination. — Eclampsia  may  end  in  cure,  in  death,  or  in  the  develop- 
ment of  another  disease,  the  result  of  the  convulsions.     Cure,  however, 
is  happily  the  most  frequent  termination,  although  the  mortality  is  very 
great.     When  the  case  is  going  to  end  happily,  one  of  the  signs  that  is 
noticed  after  the  cessation  of  the  attack  is  the  progressive  diminution  of 
the  alfoumin  which  the  urine  contains,  and  its  complete  disappearance  at- 
the  end  of  a  time  which  may  vary  from  several  hours  to  several  days.    Gl-en- 
erally  it  is  in  the  first  two  or  three  days  tliat  this  disappearance  is  noticed, 
and,  at  the  same  time,  the  urine,  which  was  almost  wholly  suppressed 
during  the  attack,  and  likewise  cloudy,  takes  on  again,  little  by  little,  its- 
normal  quantity  and  appearance.     Then  consciousness  gradually  returns, 
but  it  is  not  rare  to  see  it  remain  for  some  time,  sluggish  and  troubled. 
It  is  the  same  with  memory  and  disturbances  of  vision,  but  generally  all 
complications  cease  in  the  fortnight  after  confinement,  and  the  patients. 
recover  their  health  almost  entirely,  save  a  feeling  of  feebleness  and, 
fatigue,  which  may  last  much  longer. 

Unfortunately  it  is  not  always  so,  and  death  is  too  often  the  end  of 
eclampsia.     At  least  statistics  go  to  show  it: 

General  Morialitij  of  Eclampsia. — Lachapelle  and  Romberg,  50  per 
cent.;  Devilliers  and  Regnault,  55  percent.;  Brummerstiidt,  37  per  cent.^ 
Dohrn,  29  per  cent.;  Merriman,  23  per  cent.  Churchill,  27  per  cent.; 
Lever,  28  per  cent.;  Collins,  16  per  cent.;  Eamsbotham,  16  per  cent.; 
Murphy,  24  per  cent;  Blot,  35.5  per  cent.;  Wieger,  30  per  cent. 

According  to  Kiwisch,  one-third  of  the  women  attacked  by  eclampsia 
die  during  the  convulsive  period,  and  one-third  of  those  Avho  survive  are 
carried  off  by  secondary  puerperal  complications.  In  318  cases  collected 
by  AYieger  there  were  96  deaths.  In  60  the  cause  was  as  follows:  41 
women  died  from  eclampsia,  and  19  from  complications. 

Death  may  occur  in  different  Avays.  1st.  Death  may  come  on  before, 
during  or  after  confinement,  and  then  it  is  due,  either  to  the  attacks 
themselves  or  to  the  consequences  of  the  attack,  or  to  the  sequelae. 


116  A   TEEATISE    ON   OBSTETRICS. 

AVlien  death  comes  on  before  labor,  it  is  either  during  the  attack,  and 
although  rarely,  it  has  been  observed  by  Baudelocque,  Kiwisch,  Prestat, 
Depaul;  or  else,  and  this  is  the  rule,  it  may  come  on  during  the  period 
of  coma.  Ordinarily,  after  a  certain  number  of  attacks,  labor  comes  on, 
and  then,  indeed,  death  may  take  place  either  during  labor  in  an  attack, 
or  after  labor  in  another  attack,  or,  as  a  rule,  during  coma.  Pulmonary 
complications  are  very  common,  and  may  carry  off  the  patient;  also  pul- 
monary oedema,  congestion  or  apoplexy;  death,  even,  may  result  from 
cerebral  apoplexy  or  paralysis  produced  by  congestion,  which  in  turn  re- 
sults from  disturbances  of  respiration  and  circulation,  or  by  exti'a'^asations 
into  the  cranial  cavity,  which  may  be  either  serous  or  bloody. 

Litzmann  and  Braiin  attribute  the  cause  of  death  either  \,o  urgemic 
poisoning,  i.e.,  to  the  toxic  influence  of  the  blood  on  the  nervous  system, 
or  to  secondary  lesions  of  the  brain  or  lungs.  The  apoplexies  into  the 
cranial  cavity  or  tissue  of  the  brain  have  been  noted  by  Ohaussier,  Vel- 
peau,  Meniere,  Larcher,  Duges,  Prestat,  Bailly,  Depaul,  Charpentier,  and 
Molas,  who  has  in  his  thesis  collected  five  to  six  cases.  Blot  and  Molas 
have  noted  hemorrhages  in  the  liver.  These  hemorrhages  are  not  surpris- 
ing, for  since  Blot  noted  the  frequency  of  hemorrhages  in  connectioit  with 
albuminuria,  all  authors  have  noted  similar  cases. 

Hamilton,  Baudelocque,  Miquel,  Scanzoni,  Oazeaux  have  reported  cases 
of  rupture  of  the  uterus  during  an  eclampsic  attack;  and  Bailly  has  seen 
death  in  one  case  due  to  the  swelling  of  the  tongue,  produced  by  blood  ex- 
travasation into  the  organ,  the  result  of  the  deep  bites  inflicted  during  the 
convulsions.  In  these  cases,  death  is  no  less  rapid,  and,  in  general,  the 
women  die  in  twelve  or  twenty-four  hours  or  more  after  the  last  attack. 

2d.  Death  may  be  caused  by  complications  which  are  frequent  in  eclamp- 
sia, but  they  are  not  all  of  the  same  gravity;  and,  if  some  are  the  imme- 
diate cause  of  death,  others  may  be  only  a  predisposing  cause,  and  such 
are  hemorrhages  in  general.  Aside  from  the  blood  extravasations,  such 
as  sub-arachnoid  or  cerebral  or  hepatic  hemorrhages,  or  j)ulmonary  apo- 
plexies, which  we  have  noted.  Blot  has  called  attention  to  a  hemorrhagic 
tendency  which  eclampsic  and  albuminuric  women  have,  a  tendency  which 
shows  itself  in  epistaxis,  otorrhagia,  hematemesis,  hematuria,  but,  above 
all,  uterine  hemorrhage,  which  comes  on  during  the  third  stage  of  labor, 
and  to  which  he  attaches  great  importance,  and  which  has  been  since 
observed  by  other  authors.  If  these  hemorrhages,  indeed,  are  not  serious 
in  themselves,  they  weaken,  exhaust  the  woman,  and  predispose  her  thus 
to  puerperal  complications. 

Authors  are  agreed  in  establishing  the  frequency  with  which  puerperal 
complications  follow  eclampsia,  and  Blot  has  shown  that  these  complica- 
tions are  the  more  grave  and  serious  as  hemorrhages  have  been  severe.  In 
28  cases  of  albuminuria,  with  or  without  eclampsia.  Blot  has  observed  15 
cases  with  hemorrhages,  more  or  less  abundant,  with  6  deaths. 


DISEASES    OF    PREGiSrAlSrCY.  117 

These  complications  may  be  arranged  under  five  heads:  1st.  "Women 
may  suffer  from  puerperal  complications  (Blot,  Depaul,  Braiin,  Devilliers 
and  Regnault,  Litzmann,  Krassnig,  Dohrn,  Grenser,  Cazeaux).  These 
accideiits  are  classic,  i.e.,  peritonitis,  metro-peritonitis,  phlebitis,  lymphan- 
gitis, etc.  2d.  Women  may  die  from  meningeal  complications,  (Cazeaux, 
Pelissier).  3d.  The  albuminuria  was  dependent  upon  Bright's  disease, 
chronic  or  acute,  which  becomes  increased,  in  passing  into  a  chronic 
state,  and  may  kill  the  patient.  (Hoffmeier,  Moricke).  4th  and  5th. 
Eclampsia  may  end  in  paralysis,  or  puerperal  mania,  which  will  be  treated 
of  in  a  chapter  devoted  to  that  subject. 

We  will  only  say  here,  that  mania  is  much  more  frequent  than  paralysis, 
since  Wieger  saw  10  cases  in  140;  Grenser  4  in  19  cases;  Braiin  5  in  44 
cases,  and  Simpson  much  more  frequently  still. 

Pathological  Anatomy. — The  lesions  which  are  found  on  autopsies  of 
patients  who  die  of  eclampsia  are  so  numerous  and  varied,  that  one  might 
well  ask.  Is  there  a  pathological  anatomy  of  this  disease  ?  The  lesions  are 
found  in  the  brain,  lungs  and  kidneys,  but  it  is  impossible,  at  present,  to 
find  one  lesion  which  is  characteristic  of  the  disease,  or  constantly  pres- 
ent. The  kidney  lesions  may  be  often  wanting,  so  it  is  not  to  be  won- 
dered at  that  so  many  theories  are  advanced.  The  lesions  themselves  are 
in  no  respect  constant,  and  in  a  great  many  cases,  general  congestion  is 
only  present  to  explain  the  convidsions. 

On  referring  to  different  authors,  we  find  that  Lachapelle,  Cruveilhier, 
Baudelocque,  Ramsbotham,  Velpeau,  Scanzoni,  Cazeaux,  Kiwisch,  Jac- 
quemier,  in  a  number  of  autopsies  have  found  no  appreciable  lesion,  it 
may  be  in  the  brain  or  adnexa.  The  following  lesions  have  been  dem- 
onstrated by  others: 

Braiin,  in.  10  autopsies,  1  case  of  meningeal  apoplexy,  10  cases  of  ane- 
mia and  oedema  of  the  brain  and  its  envelopes. 

Krassnig  in  9  autopsies,  6  cases  of  anaemia  and  interstitial  serous  effu- 
sions, 1  case  of  congestion,  ]  case  of  meningeal  apoplexy;  1  case  nothing 
was  found.  Devilliers  and  Regnault,  Lever,  Hardy,  Collins,  Mac  Clintock, 
Eamsbotham,  Kiwisch,  Grenser,  Martin,  found  in  42  autopsies:  Hyperae- 
mia,  10;  anaemia,  4;  normal,  4;  serous  effusion  of  arachnoid,  7;  serous 
effusion  in  ventricles,  5;  apoplexies,  12. 

Depaul,  Blot,  Bailly,  Mercier,  Charpentier,  have  found  cerebral  hem- 
orrhages; Molas  hemorrhages  into  the  arachnoid. 

Helm,  Kiwisch,  Braiin,  congestion  of  the  membranes  and  meningeal 
apoplexy. 

Bloff,  serous  effusion  into  the  spinal  cavity. 

Braiin  found  the  brain  and  its  membranes  sometimes  anaemic  or  nor- 
mal, sometimes  congested. 

The  arachnoid  and  ventricles  sometimes  contain  fluid.  The  eye,  in 
spite  of  amaurosis,  may  be  normal,  or  the  aqueous  humor  may  be  in- 


118  A    TREATISE   ON   OBSTETRICS. 

creased  (Cucuel,  Abeille,  Orocq,  Col  lard,  Marchal);  sometimes  tiiere  may 
be  liemorrliages  in  the  retina  (Turcq);  the  blood  is  slightly  coagulable, 
and  has  a  violet  color.  In  the  lungs  there  is  always  oedema,  and  emphy- 
sema may  or  may  not  be  present,  as  Bar  has  stated.  Usually  they  are 
congested  and  contain  apoplexies.  Delmas  has  shown  that  serum 
exists  in  the  pleural  cavity.  The  spleen  and  liver  are  more  or  less  con- 
gested. Blot,  Molas,  have  found  hemorrhages.  The  changes  that  are 
most  often  met  with  are  those  in  the  kidneys,  but,  Bailly  to  the  contrary, 
they  are  not  constant,  and  if  it  is  true  that,  in  a  certain  number  of  cases, 
the  lesions  have  escaped  observation  on  account  of  the  insufficient  means 
employed  in  the  search,  the  microscope  is  not  always  able  to  find  them; 
and  although  we  think  that  there  is  an  almost  constant  relation  between 
albuminuria  and  eclampsia,  we  believe  that  in  many  cases  the  renal  lesions 
are  very  slight,  and  sometimes  they  cannot  be  found  by  the  most  careful 
research,  because  they  do  not  exist.  When  the  renal  lesions  do  exist  they 
may  be  met  with  in  the  three  forms  described  by  Frerichs. 

First  Degree.  Gommencing  Hypermmia  and  Exudation. — The  surface  of 
the  kidney  is  smooth,  the  capsule  is  easily  removed,  the  venous  plexuses 
are  dilated  and  gorged  with  dark  blood  ;  the  cortex  is  reddish-brown, 
soft  and  friable.  On  cutting  through  this  substance,  a  gelatinous  bloody 
fluid  oozes  out  which  infiltrates  the  substance  of  the  kidney.  The  pyra- 
mids are  congested.  The  mucous  membrane  of  the  calyx  and  infundibu- 
lum  is  swollen,  covered  with  congested  vessels  and  contains  a  bloody  fluid. 
Except  for  the  hypergemia,  the  substance  of  the  kidney  does  not  appear 
very  much  diseased.  Sometimes  hemorrhages  are  found  coming  from  the 
glomeruli,  again  from  the  vascular  plexus,  the  uriniferous  tubules,  or 
even  from  the  veins  spread  over  the  cortex.  The  epithelium  of  these 
tubules  is  not  yet  very  much  altered,  but  it  is  easily  detached.  The 
tubules  are  filled  with  an  exudation,  or  fluid  in  the  form  of  casts,  trans- 
parent, bloody,  constituting  fibrinous  casts. 

Second  Degree.  Exudation  and  commencing  fatty  Degeneration. — It  is 
characterized  by  a  dull,  yellow  color  of  the  cortex,  by  vascular  striae,  by 
red  spots  and  by  the  size  of  the  kidney,  the  weight  of  which  is  above  the 
normal.  Then  the  kidney  is  softer,  more  friable,  opaque  and  dull,  its 
surface  is  sometimes  smooth,  sometimes  granular,  covered  with  little  eleva- 
tions of  the  size  of  a  poppy  seed,  an  appearance  which  is  due  to  the  fact 
that  the  tubules,  whose  walls  reach  the  surface  of  the  kidney,  are  distended 
with  fluid. 

The  capsule  of  the  kidney  may  with  difficulty  be  separated.  The  pyra- 
mids are  dark  red,  the  mucous  membrane  of  the  infundibulum  is  a  dirty 
red,  the  glomeruli  are  covered  with  fine  granular  material,  and  in  places 
there  are  areas  of  fatty  degeneration.  Between  the  glomeruli  and  the 
capsule  lies  a  thick  bed  of  solid,  granular  matter,  in  which  fat  globules 
are  found  and  sometimes  rholpstoriue.     "When  the  disease  is  more  ad- 


DISEASES    OF    PREGNANCY.  119 

vanced,  the  interior  of  the  epithelial  cells,  filled  with  fat  globules,  becomes 
cloudy.  Finally,  by  the  increase  in  granules,  the  cells  themselves  become 
disorganized,  and  then  the  epithelial  cells  themselves  undergo  fatty  de- 
generation. 

Third  Degree.  Afroph/;.  — The  kidneys  may  have  returned  to  their  nor- 
mal size,  or  even  smaller,  the  capsule  has  a  dirty  white  color,  it  is  thick 
at  certain  points,  and  closely  united  to  the  cortex,  and  can  with  difficulty 
be  detached  without  bringing  away  with  it  portions  of  the  kidney.  The 
surface  of  the  kidney  has  lost  its  polish,  is  rough  and  nodular,  studded 
with  deep  depressions  or  furrows,  which  divide  it  into  lobes.  The  color 
of  the  surface  of  the  kidney  is  dirty  brown,  the  depressed  portions  seem 
like  cicatrices,  and  are  generally  pale.  They  have  at  times  a  bluish  black 
color,  due  to  old  extravasated  blood.  Generally,  some  parts  of  the  organ 
retain  their  normal  color.  The  friability  which  the  kidney  presented  in 
the  preceding  stage  gives  way  to  a  hardness  like  leather.  On  section  the 
cortex  has  more  or  less  completely  disappeared.  The  uriniferous  tubules 
are  destroyed  and  the  Malpighian  capsules  retracted,  after  the  oblitera- 
tion of  their  vascular  coat.  There  remains  no  more  of  the  destroyed  uri- 
niferous tubules  than  the  basement  substance,  which  in  its  turn  becomes 
wrinkled  and  shrivelled.  AVhen,  in  the  first  two  conditions,  a  part  of  the 
exudation  has  passed  into  the  interstitial  tissue,  it  becomes  organized, 
more  or  less  completely,  into  a  tissue  which  surrounds  the  tubules  and 
capsules  of  Malpighi,  and,  contracting  like  cicatricial  tissue,  becomes 
one  of  the  chief  causes  of  atrophy.  The  atrophy  of  the  pyramids  of  Mal- 
pighi and  of  Ferrini,  is  less  than  is  found  in  the  cortex.  There  is  found 
at  their  base,  scattered  between  the  straight  tubules,  fine  granulations 
which  compress  them,  and  separate  them  one  from  the  other.  The  calices 
are  usually  enlarged,  their  mucous  surfaces  are  thick  and  studded  with 
varicose  vessels,  which  give  them  a  bluish  gray  color.  The  mass  of  fatty 
matter  about  the  kidney  diminishes  when  the  atrophy  of  the  organ  begins 
(Braiin).  But  it  is  rare  that  this  third  stage  is  found  in  wonTen  who  die 
of  eclampsia.     The  first  two  stages  are  most  commonly  met  with. 

Diagnosis. — The  diagnosis  of  eclampsia  may  be  difficult  or  not,  depend- 
ing on  the  stage  or  period  of  the  disease  in  which  we  see  it.  It  is,  how- 
ever, particularly  during  the  period  of  convulsion  and  of  coma  that  we 
are  liable  to  be  in  error;  for  often,  the  patient  is  seen  by  the  physician, 
suddenly,  before  he  has  gained  any  information  in  regard  to  the  case, 
and  it  may  sometimes  be  very  difficult  to  reach  a  diagnosis  at  once.  The 
first  point  which  ought  to  arouse  the  suspicion  of  the  physician  is  the 
fact  of  pregnancy.  Convulsions  come  on  generally  in  the  sixth  or  seventh 
month,  i.e.,  when  the  positive  signs  of  pregnancy  have  existed  for  a  long 
time.  It  is  easy,  hence,  to  determine  pregnancy  with  certainty.  The 
urine  should  be  examined  at  once  for  the  presence  or  absence  of  albu- 
min, and  albuminuria  once  determined,  the  probability  is  that  the  convul- 


120  A    TREATISE    ON"    OBSTETRICS. 

sions,  if  there  are  any,  are  true  eclamptic  convulsions,  and  that  the  coma 
may  be  the  result  of  the  convulsions.  There  are,  however,  a  certain  num- 
ber of  morbid  states  independent  of  albuminuria,  which  may  produce 
convulsions,  followed  by  coma,  either  during  pregnancy,  labor  or  the 
puerperal  state,  which  may  lead  to  error.  We  will  review  them  rapidly. 
It  is  Braiin  who  has  gone  extensively  into  the  diagnosis,  but  as  Bailly 
remarks,  he  has  gone  much  too  far,  when  he  has  tried  to  establish  the 
differential  diagnosis  of  eclampsia,  with  the  convulsions  which  may  come 
on  in  poisoning  by  mercury,  copper,  silver,  arsenious  acid,  hydrocyanic 
acid;  by  the  use  of  the  preparations  of  hemlock,  belladonna,  tobacco,  strych- 
nine, etc.,  and  even  poisoning  from  snake  bite.  Only  lead  poisoning 
could  lead  really  to  error.  We  will  limit  ourselves  here  to  those  diseases 
which  present  phenomena  like  those  of  eclampsia,  either  during  the  period 
of  convulsions  or  coma. 

1.  Cholemic  Eclampsia. — It  is  always  joined  to  acute  yellow  atrophy  of 
the  liver,  to  typhoid  icterus,  to  pyaemia  and  to  puerperal  diseases.  It 
is  always  accompanied  by  fever,  and  the  diagnosis  ought  always  to  be 
based  on  the  diminished  size  of  the  liver,  made  out  by  percussion, 

2.  Hysteria, — The  convulsions  of  hysteria  come  on  during  very  difficult 
labors.  The  urine  never  contains  albumin.  Consciousness  is  always  pre- 
served, if  not  wholly,  at  least  very  appreciably;  sensibility  may  be  lessened, 
but  preserved.  Hysterical  convulsions  are  always  accompanied  by  other 
phenomena — globus  hystericus,  oppression,  dyspnoea,  etc.,  but  there  are 
neither  "  tonic  nor  clonic  "  convulsions.  During  the  attack,  there  is  a 
tendency  to  loss  of  consciousness,  but  there  is  no  coma  after  the  attacks, 
which  end  usually  by  the  passage  of  clear  urine,  limpid,  not  albuminous. 
These  attacks  do  not  interfere  with  the  course  of  pregnancy. 

3.  Ejjileijsy. — The  convulsions  are  chronic;  they  come  on  during  preg- 
nancy, at  intervals  of  several  days  or  weeks,  but  very  rarely  several  times 
in  the  same  day.  There  is  no  albumin  in  the  urine.  The  attacks  are 
often  preceded  by  an  "aura  epileptica."  Epilepsy  is,  moreover,  charac- 
terized by  insensibility,  and  it  is  not  rare  to  see  consciousness  return  very 
quickly  and  rapidly  after  the  attack.  Further,  in  epilepsy,  reflex  sensibility 
coincides  with  loss  of  consciousness  from  the  beginning  to  the  end  of  the 
attack.  But  it  is  the  disease  which  most  nearly  resembles  eclampsia,  for 
in  epilepsy  the  attacks  have  a  period  of  tonic  and  clonic  spasm,  and  also 
of  coma;  but  the  prodromata,  and  the  absence  of  albumin  in  the  urine, 
are  the  diagnostic  peculiarities.  We  may  add  that,  except  the  aura,  epi- 
lepsy never  presents  the  prodromata  which  are  seen  in  eclampsia,  and  that 
the  infiltration  which  is  so  frequently  found  in  albuminuria  and  eclamp- 
sia is  never  present  in  epilepsv. 

4.  When  the  woman  is  comatose,  the  diagnosis  must  be  made  between 
coma  of  epilepsy,  apoplexy,  cerebral  hemorrhage,  and  the  coma  of  alcohol- 
ism. 


DISEASES    OF    PREGaSTANCY.  121 

(A).  Coma  of  EjnUpsy. — It  is  very  difficult,  if  one  has  no  information, 
to  make  a  diagnosis  between  coma  of  epilepsy  and  that  of  eclampsia. 
The  examination  of  the  urine  may  remove  all  doubt  j  besides,  the  coma 
of  eclampsia  always  lasts  longer,  is  more  persistent  than  that  of  epilepsy. 
While  in  the  latter  consciousness  may  be  recovered  completely,  m  eclamp- 
sia consciousness  comes  back  only  slowly,  at  first  incompletely,  and  the 
patient  remains  more  or  less  time  in  a  state  of  discomfort,  which  does 
not  exist  in  epilepsy.  Memory  comes  back  much  more  slowly,  and  the 
persistence  of  disturbances  of  one  or  more  of  the  senses  are  often  noticed  — 
hearing  or  sight.  Finally,  it  is  not  rare  to  see  mania,  paralysis,  etc.,  fol- 
low eclampsia,  which  does  not  happen  in  epilepsy. 

(B).  Cerebral  hemorrhage  is  accompanied  by  hemiplegia,  no  albumi- 
nuria. 

(C).  Coma  of  drunkenness  (alcoholism)  is  diagnosticated  by  the  odor 
of  the  breath,  and  by  the  nature  of  the  vomited  material  which  is  noted 
in  these  cases.     There  is  no  albuminuria. 

(D).  But  with  epilepsy,  which  is  the  disease  most  commonly  confounded 
with  eclampsia,  lead  poisoning  must  be  mentioned.  The  latter  is  accom- 
panied by  nervous  phenomena  similar  to  those  of  puerperal  eclampsia; 
attacks  of  convulsions,  coma,  albuminuria  like  that  of  nephritic  albumi- 
nuria; but,  as  Depaul  says,  who  has  observed  a  remarkable  case,  the  coma 
is  not  as  deep — the  loss  of  consciousness  exists,  but  insensibility  is  not 
completely  lost.  The  eyelids  and  the  lips  twitch,  and  there  are  convul- 
sive movements,  but  the  head  remains  fixed,  the  other  muscles  of  the  face 
are  not  convuJsed,  and  the  tonic  and  clonic  spasm  are  incomplete.  Fur- 
ther, the  lead  line  of  the  gums  aids  the  diagnosis,  which  is  furthermore 
assisted  by  the  information  drawn  from  the  patient.  In  Depaul's  case, 
the  autopsy  revealed  the  presence  in  the  brain  of  fifteen  grains  of  lead. 
In  this  case  the  diagnosis  was  facilitated  by  the  absence  of  infiltration, 
and  also  the  absence  of  albumin  in  the  urine. 

We  only  mention  here  meningitis  and  chorea,  which  are  distinguished 
by  such  characteristics  that  an  attentive  physician  cannot  be  mistaken. 

The  application  of  the  thermometer  to  eclampsia  gives  to-day  a  much 
greater  precision  in  the  diagnosis,  which  is  remarkably  facilitated  by  the 
study  of  the  temperature.  Thus,  in  eclampsia  the  temperature  rises 
gradually  and  rapidly  from  the  beginning  of  the  attack,  and  it  continues 
to  rise  even  after  death.  (109.2°.)  In  uraemia,  the  temperature  falls 
from  the  beginning,  and  continues  to  fall  gradually  until  death,  when  it 
may  descend  even  to  98°  F.  In  some  cases,  however,  the  temperature 
stays  high  at  the  beginning,  but  always  falls  the  following  day. 

In  epilepsy,  under  the  influence  of  an  attack,  the  temperature  rises 
slightly,  but  the  highest  point  is  101.4°— the  rule  is  100.2°.  The  attack 
ended,  the  temperature  falls,  only  to  rise  again  at  the  beginning  of  a  new 
attack.     In  epilepsy,  the  temperature  curve  is  the  same  as  that  in  puer- 


122  A    TREATISE    ON    OBSTETRICS. 

peral  eclampsia;  it  rises  gradually,  stops,  and  descends  j^raduaiiy  after  the 
attacks.  It  is  then  by  the  previous  history,  and  above  all  by  the  absence 
of  albuminuria,  that  the  diagnosis  is  made.  But  when  the  epileptic  attack 
presents  the  two  periods,  convulsive  and  meningitic,  described  by  Dela- 
siauve  and  Bourneville,  at  the  beginning  there  is  an  elevation  of  temper- 
ature, then  a  depression,  which  is  succeeded  by  a  sudden  elevation  to  104° 
to  105.3°. 

In  hysteria  and  hystero-epilepsy  the  temperature  rises  during  the  at- 
tacks, but  w^here  the  attack  is  over,  it  descends  again  gradually  to  the 
normal. 

In  lead  poisoning  the  temperature  follows  the  same  course  as  in  epilep- 
sy, moreover  the  pulse  is  tricotic.  In  cerebra]  disturbances  the  tempera- 
ture does  not  rise. 

Cerehro-S'pinal  Meningitis. — The  pulse  is  slow,  and  the  temperature  pre- 
sents morning  remissions  and  evening  exacerbations.  Finally,  in  the  coma- 
tose period  of  cerebral  hemorrhage,  there  is  an  initial  lowering  of  the 
temperature,  and  then  a  much  greater  elevation  as  the  disease  is  going  to 
end  fatally. 

Cerebral  Concussion. — There  is  always  a  lowering  of  the  temperature. 

It  is  not  necessary  to  quote  a  large  number  of  statistics  of  the 
mortality  of  women  in  the  puerperal  state  to  establish  the  seriousness 
of  this  disease.  AVe  must,  in  order  to  make  our  prognosis,  seek,  in  the 
circumstances  which  accompany  eclampsia,  or  in  which  it  is  produced, 
the  elements  for  our  prognosis,  and  finally  determine  what  may  be  the 
consequences  for  mother  and  child.  We  think  that  eclampsia  shows 
itself  in  this  order  of  frequency:  1st.  During  labor.  2d.  During  |)reg- 
nancy.  3d.  During  the  puerperal  state.  Is  eclampsia  equally  serious 
during  these  three  periods,  or  is  it  more  serious  during  one  than  during 
another  ? 

First  of  all,  it  is  a  fact  admitted  by  all  authorities  that  death  rarely 
takes  place  during  the  attack,  and  that  it  is,  generally,  during  the  coma- 
tose period  or  in  consequence  of  puerperal  complications  that  the  fatal 
issue  manifests  itself. 

Contrary  to  the  opinion  of  Cazeaux  and  Eamsbotham,  who  consider 
eclampsia  more  fatal  when  it  occurs  during  the  j)uerperal  state,  Depaul 
and  Mme.  Lachapelle  believe  the  mortality  greater  when  the  convulsions 
occur  during  pregnancy  or  labor.     Here  are' the  statistics  of  Wieger: 


Before  labor,  .         .         .         , 

At  the  end  of  labor, 
During  labor  (stage  not  indicated). 
During  the  period  of  expulsion. 
After  labor,    .         .         .         .         , 


Cases. 

Cured. 

Deaths. 

65 

40 

25 

51 

33 

18 

50 

35 

15 

25 

18 

7 

62 

42 

20   • 

DISEASES    OF    PREGNANCY.  123 

Wieger  lionce  tigrees  with  Depaiil.  If  the  morttility  of  cclampsic  women 
before  and  at  term  be  compared,  we  find: 

Cases.        Cured.       Deaths. 
Eclamptic  before  term,   ....     50  37  13 

at  term,  ....     50  38  12 

The  mortality  is  then  about  the  same  in  each,  and  Wieger  is  still  in 
accord  with  l!)epaul. 

Among  the  elements  of  prognosis,  the  number  of  the  attacks  must  be 
considered.     Our  statistics  give  the  following: 

In  45  women  having  had    1  to  10  attacks  the  mortality  was  11. 
"  31       "  "         "     10  ''  20       "         "         "  "    10. 

"  24      "  "         "     21  "  50       "         "         "  "    12. 

Beyond  this  last  number,  which  varied  from  50  to  100  or  160,  accord- 
ing to  Bailly,  Cretet  and  Depaul,  we  can  make  no  statement,  the  number 
of  cases  being  too  small;  the  patients  of  Bailly  and  Pajot  were  cured. 

We  say,  therefore,  that  the  number  of  the  attacks  has  a  marked  influ- 
ence, because  the  mortality  is  increased  with  the  number  of  the  attacks; 
and  since  it  has  been  proved  that  the  number  of  the  attacks  is  far  from  be- 
ing proportional  to  the  renal  lesion,  one  is  forced  to  admit  that  the  at- 
tacks themselves  have  some  influence. 

The  information  derived  from  the  thermometer  ought  to  be  a  help  in 
making  a  prognosis.  But  it  is  not  the  maximum  temperature  which 
ought  to  guide  us,  although  it  has  some  importance.  (All  the  women, 
indeed,  who  have  died,  have  had  a  temperature  as  high  as  105.4°  or  higher, 
except  two.  In  women  who  have  been  cured,  the  temperature  has  re- 
mained below  105.4°  except  two,  in  which  cases  the  temperature  reached 
this  point).  It  is  the  course  of  the  temperature  which  enables  us  to 
make  the  following  propositions:  1.  Whenever  the  temperature,  after 
having  followed  the  ordinary  course,  i.e.,  elevated,  which  is  usual  in 
puerperal  eclampsia,  falls  slowly  and  gradually,  a  favorable  prognosis  may 
be  given.  2.  If,  on  the  contrary,  the  temperature  continues,  and  gradu- 
ally increases  and  becomes  very  high,  105°  to  106°,  an  unfavorable  prog- 
nosis can  be  given,  for,  in  these  cases,  the  eclamptic  attack  usually  ter- 
minates in  death. 

The  Influence  of  Eclamjjsia  on  the  Course  of  Pregnancy,  and  conse- 
quently on  the  Fmtus.- — This  influence  is  gloomy,  and  in  the  great  major- 
ity of  cases,  women  attacked  with  epileptiform  convulsions  are  confined 
prematurely.  (Depaul. )  Cohen  has  gone  too  far  in  affirming  that  he 
has  never  found  albumin  in  the  urine  of  any  pregnant  woman,  unless  the 
pregnancy  was  interrupted  in  its  regular  course.  Blot  has  proved  how 
exaggerated  this  opinion  is,  by  showing  that  in  the  albuminuric  women 
examined  by  him,  34  went  to  term,  7  only  had  premature  labors.  But 
in  those  cases,  it  was  a  question  of  albuminuria  and  not  of  eclampsia, 
which  has  a  differentlv  marked  influence. 


124  A   TEEATISE    ON    OBSTETRICS. 

Without  speaking  of  the  cases  in  which  eclampsia  comes  on  during 
labor,  it  is  undoubted  that  in  most  cases,  when  eclampsia  comes  on  dur- 
ing pregnancy,  before  term  or  at  term,  labor  is  induced,  and  almost  always, 
when  labor  does  not  come  on  immediately,  the  child  dies.  It  is  delivered 
later,  with  alterations  proportionate  to  the  length  of  time  which  it  has 
passed  in  the  uterus  after  its  death.  The  further  from  term  eclampsia 
declares  itself,  the  more  danger  there  will  be  for  the  child;  on  the  con- 
trary, the  more  advanced  pregnancy  happens  to  be,  the  more  chance 
there  will  be  for  the  child  to  survive,  and  these  chances  will  be  increased 
the  mare  as  the  eclamptic  attacks  supervene  in  the  few  days  preceding  full 
term,  and  the  more  rapid  the  labor  has  been,  or  has  allowed  active  inter- 
vention nearer  to  term. 

As  to  the  cause  of  the  death  of  the  child,  must. we  look,  as  most 
authors  do,  to  the  convulsions,  to  disturbances  in  the  blood,  i.e.,  to  as- 
phyxia, to  an  altered  state  of  the  blood  ?  All  these  causes  may  act,  be- 
cause a  certain  number  of  children  born  alive  die  soon  afterward,  some 
because  they  were  born  prematurely,  others  because  the  asjDhyxia  was  so 
jDronounced  that  they  could  not  be  revived.  Others,  finally,  only  die  at 
the  end  of  some  days,  and  then,  as  Depaul  says,  the  death  must  be  attri- 
buted to  congenital  weakness  or  to  convulsions,  which  seem  to  resemble 
somewhat  the  eclampsia  of  the  mother,  although  we  are  not  able  to  say 
that  the  two  conditions  are  identical. 

Van  der  Donckt  admits  that  the  death  of  the  foetus  may  result:  1st, 
from  asphyxia;  2d,  apoplexy  in  the  brain  or  cord.  According  to  G-renser, 
Litzmann  found  in  the  bodies  of  twins  born  of  an  eclamptic  mother,  a 
great  many  blood  extravasations  between  the  dura  mater  and  the  inner 
surface  of  the  skull.  The  pleura  and  the  entire  surface  of  the  lung  pre- 
sented others,  about  the  size  of  the  head  of  a  pin,  and  the  pericardium 
contained  bloody  serum.  Grenser  has  found  pin-head  ecchymoses  and 
blood  extravasations  of  the  size  of  a  lentil  seed  on  the  pleura,  pericardium, 
and  peritoneum,  in  a  case  where  there  was  a  slight  effusion  of  blood  in  the 
meninges;  3d,  to  blood  poisoning;  4th,  to  non-albuminuric  convalsions, 
coming  on  in  utero  or  after  birth  (Cazeaux,  Depaul);  5th,  finally  to  peri- 
tonitis.    (G-renser. ) 

Kiwisch  attributes  the  death  of  the  child  in  part  to  an  arrest  of  the 
circulation  in  the  placental  vessels,  during  the  attack  of  eclampsia  and 
the  resulting  asphyxia,  but  he  does  not  think  that  death  of  the  foetus  re- 
sults from  asphyxia. 

Braiin,  on  the  contrary,  thinks  that  uraemia  is  the  cause  of  the  death 
of  the  foetus.  After  the  first  or  second  attack,  the  foetus  is  already  af- 
fected, and  dies  almost  always  after  a  certain  number  of  attacks.  If  the 
mother  dies,  the  child,  which  is  delivered  by  the  Ca3sarean  section,  is  al- 
ways dead.  If  the  child  is  born  alive,  we  find  considerable  urea  in  the 
blood  which  flows  from  the  cord.     If  it  is  dead,  carbonate  of  amjnonia  is 


diseasp:s  of  pregnancy. 


125 


found  mthe  blood  immediately  after  delivery.  If  the  labor  is  premature, 
the  child  dies  in  two  or  three  days.  Urtemia  alone  can  kill  the  child 
without  eclampsia  having  developed  at  all.  The  children  of  eclamptic 
mothers  are  often  themselves  albuminuric. 

Now  we  have  seen  that  the  thermometer  shows  that  the  eclamptic  at- 
tack is  not  ura3mic,  and  also  that  the  temperature  reaches  in  eclampsia 
104°,  105°,  and  106°,  and  it  results  from  Eunge^s  researches  that  the  foetus 
dies  whenever  the  maternal  temperature  reaches  104.2°.  It  is  more 
than  probable  that,  in  the  majority  of  cases,  the  death  of  the 
fcetus  is  due  to  the  high  temperature  of  the  mothers.  In  the  cases  where 
the  maternal  temperature  does  not  reach  so  high  a  point,  death  may  be 
attributed  either  to  the  frequency  of  the  attacks,  to  blood  changes  which 
result  from  it,  or  to  blood  poisoning. 

Whatever  the  cause,  the  mortality  of  the  foetus  is  very  great.     Thus: 


Blot, 

in    58 

cases 

of  eclampsia. 

.     39  children  died. 

Moricke, 

"   104 

i  i 

.     62 

Merriman, 

"     51 

'  • 

.     34 

Scanzoni, 

"     25 

' ' 

.     16 

Champion, 

"     10 

' ' 

5 

Depaul, 

"   132 

' ' 

.     64 

Wieger, 

"  368 

a 

.   179         "         " 

748 

According  to  Braiin: 

Mortality  during  labor,         .... 
"  "      expulsion, 

"  "      the  attack  and  3d  stage,     . 

Finally,  Wieger  gives  the  two  following  tables: 
Eclampsia  before  or  during  Jabor. 


399 


Children  at  term,        \  ,r.  ^      /< 
"         before  term. 


51  per  cent. 
15 

45 


Mortality. 


Average,    27  per  cent. 
64 


, Childr 

en s 

r^na.r 

Living. 

Dead. 

oas6 

19 

29     = 

48 

28 

21     = 

49 

7 

8     = 

15 

19 

3     = 

22 

Eclampsia  before  labor, 

"         at  the  beginning  of  labor, 

"         during  labor,   .... 

"  "       the  period  of  expulsion. 

These  figures  confirm  the  propositions  which  we  made  above. 

The  prognosis  of  eclampsia  is  also  aggravated  by  the  fact  that  it  leads 
to  puerperal  complications,  metritis,  peritonitis  etc.  But  along  with 
these  serious  complications,  there  are  two  which,  if  they  do  not  lead  to 
the  death  of  the  patient,  merit  none  the  less  serious  attention.  We  refer 
to  puerperal  mania  and  paralysis. 


126  A   TEEATISE    ON   OBSTETEICS. 

In  the  following  chapters  we  will  treat  in  detail  of  these  two  condi- 
tions, and  at  present  we  will  limit  ourselves  with  what  concerns  the  di- 
rect relations  between  puerperal  mania  and  eclampsia,  before  entering 
more  carefully  into  details  in  the  chapter  on  puerperal  insanity. 

It  was  Simpson  who  first  noted  the  relation  which  exists  between 
eclampsia,  albuminuria  and  puerperal  mania.  Scanzoni  has  seen  4  cases; 
Wieger  has  seen  10  cases  in  100  eclamptic  women;  Grenser  4  times  in 
19  women;  Braiin  5  times  in  44  women;  and  it  has  also  been  observed 
by  Gooch,  Merriman^  Esquirol,  Sanchez  Frias,  Selade,  Billod,  Marce 
and  all  alienists. 

In  cases  of  this  nature,  sometimes,  the  maniacal  state  immediately 
succeeds  the  coma  which  follows  the  convulsion.  Sometimes  the  delirium 
does  not  break  out  for  twenty-four  or  thirty-six  hours  after  the  cessation 
of  the  convulsions,  when  everything  seems  to  indicate  the  end  of  all  cere- 
bral complications.  As  a  rule,  cure  follows  at  the  expiration  of  more  or 
less  time,  but  it  is  not  always  so,  and  mania  may  be  incurable  or  even 
end  in  death.  But  we  must  be  careful  not  to  confound  these  cases  of 
truto  mania  with  the  cases  of  puerperal  meningitis  with  delirium,  which 
Cazeaux  has  mentioned  among  the  terminations  of  eclampsia.  These 
may  occur  without  albuminuria  or  eclampsia,  and,  although  they  are  gen- 
erally fatal,  there  are  exceptional  cures,  as  we  observed  in  consultation, 
several  years  ago.  in  a  single  case. 

Fritz,  agreeing  with  Griesinger  and  Winckel,  divides  puerperal  mania 
into  three  categories. 

1,  Symptomatic  mania,  which  is  only  of  interest  on  account  of  the 
febrile  delirium,  which  increases  and  diminishes  with  the  affections  which 
cause  it'  2.  Puerperal  mania,  which  developes  slowly  and  a  long  time 
before  confinement,  and  gives  rise  to  the  furious  delirium  which  labor  or 
the  puerperal  state  excites,  by  becoming  the  occasional  cause;  3.  Puer- 
peral mania,  properly  so  called,  which  results  from  hemorrhages,  eclamp. 
sia,  violent  physical  and  moral  suffering,  without  hereditary  predisposition. 
In  this  last  class,  Winckel  distinguishes  two  kinds  of  mania.  In  one  the 
affection  is  acute,  the  course  rapid,  and  there  is  an  increase  in  the  tem- 
perature and  acceleration  of  the  pulse.  The  maniacal  attack  is  preceded 
and  accompanied  for  some  time  by  head-ache,  hotness  of  the  head,  photo- 
phobia, great  susceptibility  to  noise,  tinnitus  aurium  and  insomnia.  In 
the  other,  the  same  general  symptoms  are  not  observed;  the  pulse  is  nor- 
mal, or  slightly  accelerated;  the  life  of  the  patient  is  not  in  danger,  but 
the  mental  disorder  is  more  or  less  chronic,  and  persists  sometimes  indefi- 
nitely. 

It  is  the  first  of  these  two  forms  which  Simpson  and  Donkin  Scott  make 
dependent  upon  albuminuria.  Fritz,  on  the  contrary,  declares  that  there 
is  no  relation  of  cause  or  effect  between  albuminuria  and  mania.  Braiin 
says  that  the  mania  which  succeeds  eclampsia  is  afebrile,   but  he  has 


DISEASES    OF    PREGNANCY.  127 

almost  always  had  in  his  cases  a  very  marked  acceleration  of  the  pulse  and 
elevation  of  the  temperature.  If,  generally,  mania  follows  eclampsia,  it 
is  not  always  so,  and  it  may  come  on  before,  during  and  after  the  con- 
vulsions, and  he  cites  in  support  of  his  views  four  observations  which 
were  in  part  personal  and  in  part  reported  by'Leubuscher,  Grenser,  Don- 
kin,  Scanzoni,  Spiess,  Devilliers  and  Eegnault,  Esquirol,  Trousseau,  Seydel 
and  Bonifas.  Often  the  mania  has  ended  in  a  few  days,  and  again  it  has 
become  chronic;  but  in  these  there  were  hereditary  tendencies;  two  cases 
ended  fatally,  one  by  puerperal  fever,  one  in  profound  coma  coming  on 
after  an  attack  of  mania. 

From  these  observations  Fritz  has  drawn  the  following  conclusions: 
1.  In  whatever  period  eclampsia  comes  on,  it  may  be  accompanied  or 
followed  by  mania;  2.  Mental  disturbances  predispose  the  pregnant 
Avoman  to  mania  and  eclampsia,  during  and  after  confinement;  3.  During 
labor,  mania  may  appear  either  during  the  prodromic  period  of  eclampsia, 
or  during  the  interval  of  attacks,  or  else  in  the  state  following,  or  lastly 
even  several  days  after  the  cessation  of  the  attacks;  4.  It  is  not  rare  to 
see  an  interval  of  health,  more  or  less  long,  separate  two  of  these  periods. 
The  mania  is  of  short  duration  according  as  the  attacks  are  feeble,  and 
the  interval  between  the  attacks  are  longer;  5.  The  form  of  the  mental 
disturbances  which  succeed  almost  always  the  eclampsic  attacks  is  acute 
mania;  6.  In  all  cases,  a  woman  who  has  had  eclampsia  is  predisposed 
more  than  all  others  to  puerperal  mania. 

Eocher  does  not  believe  with  Fritz  that  eclampsia  is,  properly  speaking, 
the  cause  of  mania,  and  he  is  rather  disposed  to  admit  that  the  two  dis- 
eases depend  upon  the  same  lesion,  which  we  do  not  yet  know.  Never- 
theless, eclampsia  constitutes  a  predisposition  to  puerperal  mania,  which 
may  start  up  soon  after  the  complete  return  of  consciousness,  and  it  is  in 
the  organic  alterations,  more  or  less  serious,  that  we  must  seek  the  occasional 
cause.  These  having  the  same  origin,  sometimes  they  start  up  simulta- 
neously, sometimes  succeed  one  another.  To  the  cases  already  cited,  he 
adds  three  of  Plasse  D'  Einbeck,  of  which  two  were  cured,  and  one  died. 

Cortyl,  1877,  considers  puerperal  mania  following  eclampsia  as  depend- 
ing on  a  true  perversion  of  nervous  action,  which,  after  producing  disorders 
of  motion,  ends  by  provoking  outbursts  of  mental  disorders. 

Finally,  eclampsia  may  produce  paralysis,  either  of  the  senses,  blindness, 
or  deafness;  of  the  limbs,  hemiplegia,  paraplegia.  We  will  refer  again 
briefly  to  puerperal  paralysis. 

Treatment. — In  1872,  we  concluded  our  article  on  this  subject  in  the 
following  way.  "  In  presence  of  a  disease  so  serious  as  eclampsia,  it  is 
the  duty  of  the  physician  not  to  limit  himself  to  one  mode  of  treatment, 
but  he  should  have  a  choice  of  several  methods,  without  being  a  partisan 
of  any  one,  to  the  exclusion  of  all  others." 

To-day,  ten  years  later,  we  would  give  the  same  opinion,  and  although. 


128  A    TREATISE    ON    OBSTETRICS. 

numerous  works  liave  been  since  written  on  this  subject,  we  repeat  what 
we  have  just  said:  There  is  no  specific  treatment  for  eclampsia.  But  we 
are  not  on  this  account  ^wholly  helpless  when  brought  face  to  face  with 
this  disease,  and  if  we  have  no  exclusive  method  for  treatment,  it  is  no 
less  true  that  we  have  at  our  disposal  a  certain  number  of  means,  which, 
fortunately,  have  given  good  results  in  many  cases.  We  proceed  to  refer 
to  these. 

The  treatment  of  eclampsia  may  be  divided  into  two  great  classes:  the 
preventive  treatment,  the  curative  treatment.  The  last  may  be  divided 
into  the  medical  and  obstetrical  treatment. 

1.  The  Preventive  Treatment. — Does  there  exist  a  preventive  treatment 
of  eclampsia  ?  Since  we  consider  eclampsia  as  almost  ahvays  dependent 
on  albuminuria,  we  do  not  doubt  this,  and  the  best  way  to  prevent 
eclampsia  will  be  to  treat  the  albuminuria.  It  is  necessary,  then,  in  our 
opinion  to  resort  at  once  to  a  milk  diet,  continued  if  necessary  for 
weeks  or  months.  But  for  this  treatment  to  be  of  use,  it  must  be  tried 
in  a  thorough  manner,  and  it  will  be  necessary,  often,  to  overcome  the 
patient's  prejudices,  for  they  are  easily  induced  to  stop  the  treatment  as 
soon  as  they  become  a  little  better.  So  long  as  albumin  remains  in  the 
urine,  the  treatment  should  be  thoroughly  continued.  As  soon  as  the 
albumin  disappears,  it  should  be  stopped  at  once,  but  the  patients  ought 
only  to  return  slowly  and  gradually  to  their  ordinary  diet.  The  examina- 
tion of  the  urine  should  be  continued  every  four  or  five  days,  and  the 
treatment  be  renewed  if  albumin  reappears,  even  in  a  small  quantity.  If 
the  albumin  has  disappeared  for  eight  days  we  can  make  use  of  tonics, — 
quinine,  gentian,  together  with  small  doses  of  iron.  We  prefer  the  ex- 
tract of  quinine,  and  we  give  it  in  the  following  way: 


^ .  Extract  Quiniae, 

Extract  Gentianae, 

Ferri  Subcarbonatis, 

Pulv.  Ehei.              .         .         .         . 
M.  Ft.  pil.  No.  100. 

aa  4 
1 
q.s. 

aa  3i. 

gr.xv. 
q.s. 

Sig.  Take  five  or  six  pills  during  the  day. 

At  the  same  time,  the  patients  should  take  every  two  or  three  days  a 
light  purgative  (Castor  oil,  mineral  water  or  magnesia).  Since  we  have 
employed  this  treatment,  we  have  had  only  good  results,  and  it  has  been 
used  with  success  in  cases  seen  by  us  in  our  own  practice  and  also  in  con- 
sultation. Unfortunately,  there  are  cases  in  which  the  patients  have  such 
a  dislike  for  milk  that  they  can  neither  take  it  or  keep  it  down.  In  such 
cases  venesection  should  be  our  choice;  as  recommended  by  Oazeaux, 
Peter,  Depaul.  We  withdraw  from  4500  to  6000  grains  of  blood,  accord- 
ing to  the  case.  Peter  goes  further,  and  advises  wet  cups  to  the  lumbar 
region;  i.e.,  he  believes,  "that  the  dreaded  urgemic  complications 
should   be   guarded  against   by   general   blood-letting ;    that    the   renal 


DISEASES    OF   PREGNANCY.  129 

congestion  should  be  relieved  by  local  blood-letting,  this  renal  con- 
gestion being  the  first  and  only  cause  of  the  disease.  The  congestion 
of  the  kidneys  may  also  be  relieved  by  purgation,"  Besides  the  means 
given  above,  others  have  advised  numerous  agents  in  which  we  have  little 
confidence. 

Diuretics. — These  are  recommended  with  more  or  less  reserve  by  Fre- 
richs,  Braiin,  Pajot,  Cazeaux.  Bailly  prefers  vegetable  diuretics.  The  in- 
fusion of  triticum  repens,  addhig  or  not  some  nitrate  of  potash,  squills 
or  digitalis.  Brai^in  advises  the  use  of  vapor  baths  and  also  seltzer  water 
and  Vichy.  Frerichs,  theoretical]}^,  advises  benzoic  acid,  lemon  juice,  or 
tartaric  acid,  with  the  hope  of  neutralizing  the  carbonate  of  ammonia 
produced  in  the  blood  by  the  decomposition  of  urea.  Tannin,  iodide  of 
potassium  and  extract  of  aloes  have  also  been  recommended;  Johnson  and 
Collins  have  recommended  emetics. 

Unfortunately  all  these  means  have  an  uncertain  action,  and  venesec- 
tion even,  whether  it  be  general  or  local,  does  not  always  suffice  to  pre- 
vent the  attack.  Therefore,  with  certain  restrictions,  we  have  seen  that 
Tarnier  recommends  the  induction  of  premature  labor  as  a  means  o£  pre- 
venting eclampsia.  We  have  given  reasons  which  have  induced  us  to  reject 
it.     "We  will  n-ot  refer  to  them  here. 

[Nevertheless,  the  induction  of  premature  labor  meets  with  the  ap- 
proval of  most  American  accoucheurs,  provided  that  other  means  have 
been  tried  faithfully.  It  will  be  suificient,  in  this  connection,  to  quote  the 
words  of  our  distinguished  teacher  and  Avriter,  Lusk,  of  New  York,  who 
says,  •'  My  own  convictions  are  clear  that,  so  soon  as  grave  cerebral  symp- 
toms develop,  the  period  of  folded  hands  has  passed.  The  relief  to  be 
obtained  from  chloral  and  catharsis  is,  as  a  rule,  of  short  duration,  and 
we  cannot  go  on  giving  chloral  and  cathartics  to  the  end  of  gestation. 
Moreover,  it  is  necessary  to  take  cognizance  of  the  well-being  of  the 
foetus,  which  is  threatened  by  the  continued  circulation  of  urea  in  the 
maternal  blood.  The  induction  of  premature  labor  is  attended  by  but 
moderate  risks,  if  resorted  to  after  the  uremic  symptoms  have  been  got 
fairly  under  control.  If  employed  as  a  last  resort,  its  use  then  partakes 
rather  of  the  nature  of  a  forlorn  hope.  So  far  as  my  own  experience 
goes,  however,  the  practice  of  waiting  npon  nature  has  proved  uniformly 
disastrous,  whilst  the  induction  of  labor  has  furnished  me  with  a  certain 
proportion  of  recoveries. " — Ed.  ] 

During  .Confinement. — Bailly  advises  the  use  of  baths,  of  chloroform, 
and  the  termination  of  labor  as  rapidly  as  possible.  We  endorse  the 
opinion  of  Bailly,  excepting  the  baths  and  chloroform.  We  prefer  chloral 
to  chloroform.  But  we  are  not  agreed  with  him  in  regard  to  the  prophy- 
laxis of  eclampsia  after  labor.  Bailly  says  that  the  rapid  delivery  of  the 
placenta  and  blood  clots  is  necessary.  We  cannot  believe  that  he 
advises,  by  the  words  extraction  of  the  placenta,  the  artificial  de- 
VOL.  II.— 9. 


130  A    TREATISE    ON    OBSTETRICS. 

livery  of  the  placenta.  He  knows  better  than  any  one  the  dangers 
and  difficulties  of  the  operation,,  and,  moreover,  the  manipulations 
which  are  necessary  would  in  themselves  be  sufficient  to  produce  an 
attack  of  eclampsia.  On  the  other  hand,  although  we  are  advised  to 
deliver  the  placenta  as  soon  as  possible,  this  is  only  practicable  when  the 
placenta  is  detached.  Nature  alone  should  indicate  when  one  could  or 
should  deliver  the  placenta.  As  to  general  blood-letting  after  labor,  we 
think  that  it  only  should  be  resorted  to  in  exceptional  cases,  for  nature 
alone  should  interfere  in  these  cases.  All  accoucheurs,  since  Depaul  has 
called  their  attention  to  this  point,  have  noted  the  frequency  of  uterine 
hemorrhage  during  the  third  stage,  in  albuminuric  women.  It  must  be 
one  of  two  things.  If  the  hemorrhage  is  useful,  why  should  we  be  eager  to 
stop  it?  Or  if  it  is  useless,  why  should  it  be  replaced  by  general  blood- 
letting ? 

It  is  true  that  in  the  last  case,  the  amount  of  blood  wished  to  be  with- 
drawn can  be  controlled;  while,  in  the  uterine  hemorrhage,  the  loss  may 
be  considerable,  but  there  will  always  be  time  enough  to  interfere  and 
stop  this  hemorrhage  before  it  reaches  serious  proportions.  There  is  still 
another  reason  why  we  do  not  advise  venesection  after  delivery.  Albu- 
minuric women  are,  by  the  fact  of  the  disease  alone,  predisposed  to  puer- 
peral complications,  and  those  who  have  had  hemorrhages,  are  even  more 
apt  than  all  others  to  suifer  from  complications.  Certain  authors  have  gone 
further,  and  said  that  puerperal  mania  has  been  produced  by  frequent 
and  copious  bleeding,  and  by  the  angemia  which  is  the  result.  In  such 
cases  we  limit  ourselves  to  medical  treatment,  and,  above  all,  to  a  milk 
diet  as  long  as  albumin  remains  in  the  urine. 

11.  Curative  Treatment. 

Medical  Treatment. — The  eclampsic  attack  has  appeared  and  the  preg- 
nant woman,  during  labor  or  after  delivery,  is  in  its  power,  either  because 
the  albuminuria  was  not  recognized  or  treated,  or  it  may  be  because  the 
milk  cure,  or  preventive  treatment  has  failed.     What  is  to  be  done? 

Before  entering  into  the  discussion  and  into  the  valuations  of  the  two 
great  methods  of  treatment,  the  antiphlogistic  and  the  anaesthetic  treat- 
ment, there  are  a  few  little  points  that  it  will  be  best  not  to  overlook,  for 
they  are  aj)plicable  to  all  cases,  and  when  they  are  disregarded,  they  may, 
sometimes,  cause  complications  more  or  less  serious. 

During  an  eclamptic  attack,  the  patient  becomes  completely  unconscious, 
suddenly,  even  in  a  moment.  The  horizontal  position,  both  during  and 
after  the  attack  is  indispensable,  and  this  position  will  be  of  advantage, 
because,  in  general,  during  the  attack,  patients  are  not  at  all  likely  to 
change  their  position.  Unfortunately,  it  happens  too  often  that  eclamptic 
women  are  taken  by  surprise  and  fall  unconscious,  and  are  thus  exposed 


DISEASES   OF    PEEGXANCY.  131 

to  those  lesions  whicli  are  seen  in  epileptic  cases  (wounds  and  burns)  which, 
although  they  have  no  influence  on  the  attack,  may  retard  the  cure. 

Airing  the  room,  loosening  the  clothing,  in  a  word,  every  thing  which 
facilitates  the  free  movement  of  the  chest,  have  a  true  influence,  and  there 
is  another  cause  still  which  may  aggravate  the  condition  of  the  patient, 
the  distension  of  the  bladder.  The  urine,  it  is  true,  is  not  secreted 
abundantly  in  eclampsia  (so  little  is  secreted  that  sometimes  it  is  difficult 
to  procure  enough  to  establish  the  presence  of  albumin),  but,  in  some 
exceptional  cases,  the  bladder  is  so  distended  with  urine  that  it  may  be 
the  cause  of  serious  complications,  and  Lamotte  has  cited  two  cases  in 
which  the  convulsions  seemed  to  depend  directly  on  this  distension,  since 
the  evacuation  of  the  urine  by  the  catheter  caused  it  to  cease  at  once. 
One  should  never  forget  to  see  that  the  bladder  is  empty. 

Often,  also,  patients  are  worried  by  attendants  who  wish  to  restrain 
them.  A  careful  watching  of  tiie  patient  is  all  that  is  necessary,  because 
touching  often  excites  a  patient,  and  at  times  it  may  be  the  means  of 
renewing  the  eclampsia.  Auscultation  and  abdominal  palpation  should 
be  resorted  to  only  exceptionally,  and  only  when  it  is  necessary  to  be  sure 
of  the  condition  of  the  child.  All  the  more  is  this  true  of  the  vaginal 
touch,  which,  whether  the  prostration  of  the  patient  is  real  or  apparent, 
produces  nearly  always  in  her  a  feeling  of  revolt  or  repulsion,  which  makes 
itself  known  by  a  low  groan  or  even  by  some  excitement,  and  may  pro- 
duce the  eclamptic  attack  itself.  This  abstention,  however,  has  its  limits, 
and  one  should  not  forget  that  frequently  labor  comes  on  during 
eclampsia,  that  it  may  be  extremely  rapid,  that  dilatation,  scarcely 
commenced  when  we  first  examine,  may  take  place  in  a  few  hours 
or  less,  and  that  uterine  contractions,  continuing  to  take  place  in  spite 
of  the  coma,  may  overcome  the  resistance  of  the  cervix  and  of  the  perine- 
um, and  expel  a  child  which,  if  it  survives,  is  exposed  to  all  the  risks 
consequent  upon  unexpected  delivery.  It  is  best  then  to  assure  ourselves 
from  time  to  time,  by  examination,  in  regard  to  the  progress  of  the  labor 
in  the  interest  of  the  child.  Another  reason  is  that  thus  we  may  know 
the  time  when  intervention  is  possible,  an  intervention  which,  if  it  is  not 
always  in  the  interest  of  the  mother,  as  we  shall  see,  is  so  for  the  child 
in  a  certain  number  of  cases.  * 

At  the  beginning  of  the  attack  the  tongue  hangs  outside  the  mouth, 
and  the  spasmodic  closure  of  the  jaws  exposes  it  to  cuts  and  tears,  which 
are  accompanied  by  swelling,  impeding  respiration  and  deglutition,  not  to 
speak  of  hemorrhage.  The  tongue  must  be  replaced  and  kept  behind 
the  jaws  or  teeth.  It  has  been  advised  to  place  between  the  teeth  a 
handle  of  a  spoon,  a  cork,  a  piece  of  cloth  or  wood.  These  agents,  how- 
ever, are  not  without  their  inconveniences,  and  Depaul  has  in  his  museum 
a  piece  of  wood  nearly  5.5  inches  long,  which  did  considerable  damage. 
This  piece  of  wood,  first  placed  between  the  jaws,  was  displaced  by  one 


132  ^  A   TEEATISE   OlST    OBSTETEICS. 

end;  it  sank  into  the  oesophagus,  and  injured  the  ranine  artery  under  the 
tongue,  from  which  there  was  a  severe  hemorrhage,  which  did  not 
kill  the  patient,  but  was  only  stopped  by  the  use  of  the  cautery.  The 
sim])lest  way  consists  in  replacing  the  tongue  behind  the  teeth  at  the 
beginning  of  the  attack,  and  to  keep  it  there  by  the  use  of  a  cloth  held  by 
both  hands  during  the  attack. 

The  two  principal  methods  of  treatment  at  present,  are:  1st.  The 
antiphlogistic.  2d.  The  anesthetic  method.  Each  of  these  methods 
has  ardent  admirers  and  violent  opponents.  Should  preference  be  given 
to  one,  or  will  advantage  be  gained  by  using  them  together  ?. 

A,  Antijjhiogifstic  Method. — General  and  local  blood-letting,  purgatives, 
revulsives. 

(a).  General  Blood-letting. — This  was  formerly  the  prevailing  opinion, 
and  Mauriceau,  Dionis,  Sauvages,  Dewees,  Burns,  Hamilton,  Chaussier, 
Baudelocque,  and  also  P.  Dubois,  Cazeaux,  and  above  all  Depaul  and 
Peter,  are  the  defenders  of  this  theory,  which  counts  among  its  adversa- 
ries such  men  as  Braiin,  Maygrier,  Peterson,  Kiwisch,  King,  Blot,  Camp- 
bell, Sedywick,  Churchill,  Litzmann,  Williams,  Miquel,  Schwartz, 
Legroux,  Thomas,  etc.  But  even  among  its  advocates  there  is  a  differ- 
ence of  opinion.  It  is  only  necessary  to  cite  the  two  professors  of  the 
French  school:  while  Depaul  favors  copious  and  frequent  bleeding,  Pajot 
states  that  "  he  has  seen  the  method  employed  so  often  without  success, 
that  he  does  not  advise  it.  He  has  not,  ho  wever,  banished  bleeding  com- 
pletely in  the  treatment  of  puerperal  eclampsia;  in  certain  robust  and  ple- 
thoric women  it  is  useful." 

Thus  Depaul  does  not  hesitate  to  withdraw  at  least  30,000  grains  of 
blood  from  a  woman  in  a  few  hours.  Dewees  proposes  to  bleed  at  each 
attack.  Hamilton  proposes  to  withdraw  three  pounds  of  blood  and  repeat 
the  operation  if  necessary.  The  bend  of  the  knee  is  the  situation  most 
usually  selected.  A  sufficiently  large  vein  is  opened  to  obtain  a  rapid 
and  continuous  flow,  and  this  is  not  always  easy  on  account  of  the  move- 
ments of  the  patient.  Bleeding  is  practised  at  any  time  when  the  convul- 
sions appear,  before,  during,  or  after  labor,  with  this  exception,  that  one 
ought  to  consider,  in  cases  when  the  disease  comes  on  during  or  after 
labor,  the  amount  of  blood  lost  at  delivery.  In  acting  thus,  says  Barquis- 
sau  (1876)  "one  diminishes  the  general  mass  of  the  blood,  one  relieves 
the  nerve  centres,  which  have  a  tendency  to  become  congested,  and  by 
making  the  spinal  bulb  ansemic  we  deaden  reflex  irritability,  which  keeps 
up  the  hypergemia,  and  by  which  the  convulsive  attack  may  be  revived." 

The  advocates  of  moderate  blood-letting,  compared  with  copious  and 
repeated,  believe  that  the  advantages  of  extensive  blood-letting  are 
more  than  counterbalanced  by  the  serious  complications  in  the 
present  and  in  the  future.  For  the  present,  it  is  to  be  feared  that 
depletion,  carried  beyond  certain  limits,  would  itself  become  a  cause  of 


DISEASES    OF    PREGNANCY.  133 

irritation  to  the  brain  and  spinal  cord,  as  is  the  case  after  profuse  hemor- 
rhages, of  which  the  final  symptoms  are  almost  always  convulsive.  For 
the  future,  tlie  bleeding  impoverishes  the  blood  of  an  eclamptic  patient, 
whose  blood  is  already  very  poor,  and  forces  the  unfortunate  patient  into 
a  cliloro-ansemic  state,  the  intensity  and  persistency  of  which  may  give 
rise  to  great  alarm.  Lee,  in  19  cases  in  which  he  withdrew  a  large 
amount  of  blood,  has  reported  19  deaths,  and  35  cases  cured  in  35  patients 
where  the  blood-letting  was  moderate.  Braiin  himself,  who  is  so  op- 
posed in  a  general  way  to  bleeding,  accepts  moderate  blood-letting  in 
robust  and  plethoric  women.  There  results  from  statistics  at  our  Clinic 
the  following: 

Cured.  Deaths.  Mort. 
58  women  having  been  bled  once  with  or  without  leeches,   34      24      41.3  per  cent. 
24      "            "        several  bleedings,        .        .        .        .     11      13      54  " 

General  mortalit}'  by  bleeding, 45  " 

The  conclusion  to  be  drawn  from  these  statistics  is  that  moderate  vene- 
section is  always  followed  by  a  less  mortality  than  the  more  copious  bleed- 
ing. Therefore  we  prefer  moderate  bleeding,  although,  aside  from  the 
general  action  on  eclampsia,  we  can  state  the  following  facts: 

First  and  most  often,  the  pulse  undergoes  marked  changes;  although 
it  may  be  very  feeble,  it  becomes  less  rapid  and  stronger,  being  easily  felt 
under  the  finger;  this  is  one  of  the  first  and  most  evident  effects  of  bleed- 
ing. But  there  is  still  another  effect  which  it  is  well  to  state,  although 
in  many  cases  it  is  not  constant,  i.e.,  that  nearly  always  there  is  a  greater 
interval  between  the  attacks.  This  is  undoubted,  for  in  a  certain  num- 
ber of  observations,  in  those  cases  in  which  the  attacks  continued  in  spite 
of  the  bleeding,  their  violence  was  lessened  and  the  intervals  which 
separated  the  attacks  was  greater.     In  297  cases  gathered  from  various 

authors,  we  find: 

Cases.  Cured.  Deaths. 
Bleeding'  useless  or  inappreciable,    ....        72        55        17 
Attacks  increased  in  spite  of  the  laleeding,      .        .        46        14        32 
"        diminished  or  ceased  after  bleeding,  .        .        92        86  6 


210      155        55 


155  cured;  55  deaths;  mortality,  26.1  per  cent. 


Cases.    Cured.  Deaths.     Mort. 
One  bleeding,         .         .        .         .         .     Ill        66        34        30.6  per  cent. 
Bleeding  repeated  and  frequent,  .      83        65        18        21.6        " 

In  54  cases  at  the  Maternity,  general  mortality  by  bleeding,  34.7  per 
cent. 

Cases.  Cured.  Deaths.  Mort. 
Repeated  bleeding,       .        .        .        .13         8         4        23.3  per  cent. 
One  bleeding, 13  7  4        36 

It  is  seen  from  these  tables,  which  have  a  total  of  494  cases,  that  a  con- 
clusion cannot  be  draAvn,  for  in  comparing  them  we  obtain : 


134  A   TREATISE    ON   OBSTETRICS. 

General  Mortality  of  Bleeding  Compared. 

One  bleeding.  Repeated  bleeding. 
Clinic,  .  45  per  cent.  41.3  per  cent.  54  per  cent. 
Observations,  26  "  30.6        "  21.6 

Maternity,       34.7       "  36.3        "  33.3 

While  in  tlie  Clinic,  where  the  repeated  bleeding  is  used  with  greatest 
severity,  the  mortality  has  risen  to  54  per  cent.,  exceediiig  considerably 
the  mortality  of  single  bleeding,  in  our  own  observations  and  at  the 
Maternity,  on  the  contrary,  the  mortality  of  single  bleeding  exceeds  that 
of  repeated  blood-letting.  It  is  impossible,  therefore,  to  draw  any  con- 
clusions in  favor  of  one  or  the  other  method,  and  we  can  only  state  the 
favorable  influence  which  blood-letting  has  on  the  course  of  the  attacks. 
This  is  one  reason  why  bleeding  should  not  be  discarded  entirely. 

(b).  Purgatives. — Together  with  this  method,  purgatives  must  be 
mentioned.  Those  which  are  constantly  and  with  good  reason  employed 
(because  they  are  easily  managed)  are  calomel  and  jalap,  to  which  we 
can  add  other  purgatives,  senna,  sulphate  of  soda,  etc.  These  only  act 
as  adjuvants. 

(c).  Emetics. — We  reject  all  emetics,  in  spite  of  the  fact  that  Legroux 
advocates  them.  Collins  classes  them  with  bleeding  and  calomel,  and  he 
is  supported  in  this  by  Lever,  Johnson  and  Johns.  It  is  difficult  to  assign 
to  each  of  these  therapeutic  agents  the  part  which  belongs  to  them. 

Reviilsives. — We  have  entirely  given  up  the  use  of  sinapisms,  blisters, 
etc.  Besides  the  irritation  they  produce,  they  may  cause  ulcers,  more 
or  less  severe,  or  gangrene  sometimes  so  extensive  as  to  alone  cause  the 
death  of  the  patient. 

We  believe  the  following  are  useless,  if  not  dangerous:  Fly  blisters, 
sprinkling  the  abdomen  with  cold  water  (Denman),  ice  applied  to  the 
head,  cold  baths,  anti-spasmodics,  camphorated  ether,  valerian,  assafcet- 
ida.  Bromide  of  potash  has  seemed  to  be  useful  and  efficient  in  some 
cases,  and  "Trousseau  has  prevented  an  attack  by  compressing  the  carotids 
on  each  side. 

Jaquet  has  advised  the  use  of  a  wet  pack,  and  Porter  seems  to  have 
had  very  good  results  from  this  treatment. 

Brummerstadt  recommends  opium,  but  it  should  be  given  freely  to 
have  the  desired  effect.  According  to  him,  at  the  first  onset  of  the  attack, 
1  to  2  grains  of  pure  opium  (or  a  corresponding  amount  of  the  tincture) 
must  be  given,  and  later  -J-  a  grain  taken  after  each  attack  antil  narcot- 
ism is  reached.  It  must  also  be  given  after  the  last  attack.  Subcutaneous 
injections  of  morphine  may  be  preferred. 

[In  this  country  many  observers  have  obtained  better  results  in  the 
treatment  of  eclamptic  seizures,  from  the  subcutaneous  administration  of 
opium,  than  from  any  other  method.  It  acts  as  quickly,  nearly,  as  chloro- 
form, and  does  not  alarm  the  pntient  to  such  a  de^'ee.   The  injection  should 


DISEASES    OF    PREGNANCY. 


135 


be  given  in  full  doses  at  once,  one  grain  of  morphia  at  least,  and  boldly- 
repeated  with  the  recurrence  of  fresh  attacks.  For  our  part,  if  the  con- 
vulsions did  not  yield  to  morphia,  we  believe  that  the  immediate  termi- 
nation of  labor  offers  the  patient  the  best  chance. — Ed.] 

Lately,  subcutaneous  injections  of  pilocarpine  have  been  tried  in  doses 
of  -y-  grain,  repeated  if  necessary,  and  it  h*is  been  tried  to  induce  labor  by 
means  of  it,  and  again  as  a  means  of  treating  the  eclamptic  attacks.  "We 
will  confine  ourselves  here  to  this  last  effect,  and  reserve  for  further 
consideration  the  ecbolic  effects  of  pilocarpine.     Here  are  the  results: 


Massmann, 

2  cases 

2  cures. 

Feliling,  . 
Prochownick, 

2     "  (1  hopeless)  2     "            Infus.  Jat 

Bidder,    . 

2     " 

2     " 

Ludwig,  . 

1  case 

1  death. 

Strognowski, 

1     " 

1  cure. 

Schramm, 

2  cases 

2  cures. 

Boegehold, 

3     " 

arsemic, 

3     " 

Pasquali, 
Braiin,     . 

1  case 
1     " 

1  cure. 
1     " 

Barker,    . 

Sanger,    . 

6  cases 
3     " 

6  pulmonary  complici 
3 

Kleinwachter 

.4     '^   i 

albuminuric;  2  cures,  2  failures. 

Galabin,  . 

1  case, 

failure; 

success  with  chloroform. 

Nowitzki, 

2  cases 

1  cure,  1  death. 

Hamilton, 

1  case 

1     " 

In  34  cases  where  pilocarpine  has  been  used  for  eclampsia,  it  acted  Avell 
in  20  cases,  2  cases  died;  9  cases  had  such  pulmonary  complications  that 
it  had  to  be  given  up. 

The  results  seem  very  encouraging;  unfortunately,  these  cases  prove 
very  little,  for  pilocarpine  has  almost  never  been  given  alone,  but  it  has 
been  associated  with  venesection,  chloroform,  or  other  means,  douches, 
sounds  intended  to  produce  an  abortion.  It  is  thus  difficult  to  say  what 
part  pilocarpine  alone  had  in  the  cure. 

Sanger,  who  has  written  the  most  complete  work  on  pilocarpine,  con- 
cludes that  it  is  not  an  ecbolic  primarily,  that  it  cannot  bring  oil  uterine 
contractions,  but  only  reinforce  and  regulate  them.  1st,  When  the  cervix 
is  more  or  less  dilated,  even  when  there  are  no  true  uterine  contractions 
(the  period  of  false  pains),  pilocarpine  may  produce  labor.  2d.  "When 
there  are  irregular  pains,  pilocarpine  will  regulate  them.  3d.  During 
the  period  of  dilatation  and  expulsion,  pilocarpine  is  a  means  of  making 
the  labor  more  rapid,  by  regulating  the  pains  and  making  them  stronger 
and  more  frequent;  and  when  the  head  is  delayed  by  the  feebleness  of  the 
pains,  pilocarpine,  by  shortening  the  confinement,  may  take  the  place  of 
forceps.  The  danger  and  inconveniences  are  easily  overcome  by  the  use 
of  atropine,  which  is  the  physiological  antidote. 

As  to  eclampsia,  pilocarpine  by  injection,  is  only  successful  in  cases  in 


136  A    TREATISE    ON    OBSTETRICS. 

wliicli  it  will  produce  sweating  and  salivation,  or  at  least  the  latter.     In 
these  cases  alone  caa  it  replace  other  therapeutic  means. 

In  dangerous  cases  it  ought  not  to  be  used  exclusively.  One  of  its  ad- 
vantages is  to  accelerate  labor.  Barker,  on  the  contrary,  who  has  used  it 
in  six  cases,  has  seen  bad  results  from  it  in  every  case,  either  in  the  heart 
or  lungs,  and  does  not  believe  that  it  should  be  used  in  eclampsia,  and 
accepts  it  only  as  an  adjuvant.  Kroner  has  always  seen  it  fail,  both  as 
an  ecbolic  and  as  a  cure  of  eclampsia.  Finally  Marti- Autet,  collecting 
the  observations  of  different  authors,  and  the  experiments  of  Hyernaux 
and  Chantreuil,  has  arrived  at  the  following  conclusions: 

1.  In  a  great  number  of  cases,  subcutaneous  injection  of  pilocarpine 
has  given  a  negative  result.  It  has  not  brought  on  uterine  contractions. 
(Welponer,  Parisi,  Hyernaux,  Sanger.) 

2.  There  has  been  the  same  result  in  a  number  of  experiments  on  ani- 
mals.    (Hyernaux,  Chantreuil.) 

3.  Under  special  conditions,  the  subcutaneous  injection  of  pilocarpine 
seems  to  cause  uterine  contraction,  when  the  woman  or  animal  experi- 
mented on  is  already  in  labor  or  has  arrived  at  term. 

4.  Under  these  conditions,  the  uterine  contractions  come  on  some  min- 
utes after  the  injection  of  the  pilocarpine;  they  increase  in  frequency  for  a 
time,  then  remain  stationary,  and  finally  diminish.  Eenewed  injections 
give  like  results.     (Klein wiichter,  Sanger.) 

5.  At  times  the  action  "is  sufficient  to  expel  the  foetus.  (Schauta,  San- 
ger, etc.) 

6.  Now  and  then  the  action  has  been  insufficient  to  expel  the  foetus. 
(Sanger.) 

7.  Hence,  it  seems  reasonable  to  assume,  that  if  pilocarpine  is  given  at 
term  or  during  labor,  it  seems  to  have  a  real  influence  on  uterine  contrac- 
tions; before  term,  subcutaneous  injections  of  pilocarjDine  are  usually  in- 
sufficient to  produce  premature  labor. 

All  these  agents  are  really  palliatives  or  adjuvants,  and  if  they  are 
useful  in  some  cases,  they  fail  in  many  others.  They  cannot  then  consti- 
tute, so  to  speak,  a  method  of  treatment.  G-enerally,  they  have  been  com- 
bined with  venesection,  chloroform,  chloral,  and  premature  labor,  there- 
fore, it  is  not  possible  to  say  just  what  has  been  useful.  Eclampsia  is  es- 
sentially rapid  in  its  course,  and  a  great  number  of  these  drugs  are  slow 
in  their  action;  therefore  we  think  that  they  will  be  more  successful  if 
they  are  not  employed  alone,  but  are  associated  with  other  means,  and 
in  particular  Avith  venesection  i.e.,  the  antiphlogistic  treatment. 

B.  Ancesthetic  Method. — Three  agents  are  usually  employed.  Ether, 
which  has  given  place  to  chloroform,  and  lately  chloral.  In  15  cases  re- 
ported by  us  in  which  ether  was  employed: — influence  none  or  not  evident, 
2  deaths  in  3  cases;  aggravation  of  the  course  of  the  disease,  4  deaths  in 
4  cases;    diminution  or  cessation  of  the  attacks,  8  cures  in  8  cases.     The 


DISEASES    OF    PREGNANCY. 


137 


general  mortality,  then,  is  about  40  per  cent.  But  since  the  substitution 
of  chloroform  for  ether,  the  ani\esthetic  method  as  applied  to  eclampsia 
has  been  thoroughly  tried,  and  has  given  some  authors  most  surprising 
results.  Unfortunately,  contradictory  facts  have  been  collected,  and  we 
think  that  anesthetics,  no  more  than  venesection,  can  be  considered  an 
heroic  remedy  for  eclampsia.     Is  the  method  rational  ? 

The  opponents  of  chloroform  object  to  it  on  the  grounds:  1.  In  a  great 
many  cases  not  only  are  the  attacks  not  diminished  under  the  influence 
of  an  anesthetic,  but  they  come  on  more  frequently,  and  more  strongly. 
2.  Although  chloroform  arrests  the  attacks,  they  reappear  in  the  in- 
terval between  the  inhalations,  and  the  woman  cannot  be  kept  under 
chloroform  for  some  time  without  danger.  3.  Chloroform  is  irrational, 
because  it  produces  congestion  of  the  nerve  centres,  and  may  thus  in- 
crease cerebro  spinal  congestion,  which  is  already  so  much  dreaded  in 
eclampsia.  4.  Chloroform  increases  the  asphyxia  of  eclamptic  subjects 
already  predisposed  to  this  complication;  5.  The  use  of  chloroform  in 
some  eclamptic  cases  has  been  followed  by  the  appearance  of  puerperal 
mania. 

Depaul,  finally,  who  is  one  of  the  most  determined  opponents  of  chloro- 
form, admits  that  it  does  modify  to  a  certain  extent  the  attacks  of  eclamp- 
sia, but  they  exist,  none  the  less,  as  well  as  all  the  complications  that  go 
with  them — congestions,  central  hemorrhages,  pulmonary  congestion,  etc. 

The  opinions  of  authors  are  divided  on  this  subject;  while  Eichet, 
Gros,  Sprengler,  Scanzoni,  Bralin,  Spath,  Meinsinger,  Blot,  Charrier, 
Eichardson,  Bazin,  Macario,  AVittle,  Liegeard,  Maugenest,  Fearnet, 
Derby,  Kiwisch,  Wieger,  Chailly,  Ohanning,  Campbell,  Schneiseson, 
Schroeder,  Spiegelberg,  are  advocates  of  this  method,  others,  as  De- 
paul, Pajot,  Tarnier,  Jacquemier,  Gueniot,  Bailly,  are  more  conservative, 
or  even  reject  it  all  together. 

We  believe  that  it  is  not  at  all  necessary  to  accept  it  exclusively,  nor 
reject  it  absolutely;  and,  if  chloroform  has  failed  in  a  good  many  cases 
(we  have  had  in  our  own  practice  an  unfortunate  example),  there  are 
others  where  it  has  rendered  excellent  service.  In  one  article  we  collected 
63  cases  in  which  chloroform  had  been  administered  by  inhalation  or  in- 
ternally, and  the  following  are  the  figures: 


Cases. 

Cures. 

Deaths. 

Mort. 

Cases  in  which  the  influence  has  been  nil  or 
could  not  be  noticed,  .... 

Cases  in  which  tlie  disease  has  not  been 
arrested,       

Cases  in  wliich  the  attacks,  at  first  modified, 
have  ceased. 

8 

6 

49 

6 

2 

48 

3 
4 
1 

25  per  cent. 
33.3     " 

2.4     " 

The  figures  of  the  average  mortality  are  only  raised  to  11  per  cent.,  but 


138  A    TEEATISE    ON    OBSTETRICS. 

this  we  believe  is  too  small,  and  because  the  successful  cases  have  been 
published  and  the  unsuccessful  ones  not.  Nevertheless,  taking  the  highest 
figure  of  the  mortality,  i.e.,  in  the  unfortunate  cases — 33  per  cent.,  and 
we  have  pretty  nearly  the  figures  obtained  by  us  in  the  Maternity  by 
venesection — 34  per  cent. ;  and  a  much  lower  figure  than  at  the  Clinic — 45 
per  cent.  This  v/ould  seem  to  settle  the  question,  but,  on  the  other  hand, 
if  we  compare  all  statistics  at  the  Maternity,  we  find  that  the  mortality 
by  bleeding  is  34.  T  per  cent. ;  by  the  use  of  chloroform,  50  per  cent.  The 
results,  therefore,  are  somewhat  contradictory. 

.    Bleeding'.  Chloroform. 

Clinic,    .         .         .         .         .45   per  cent  33.3  per  cen 

Maternity,      .         .         .         .     34.7     '^  50 

The  use  of  chloroform  once  granted,  how  should  it  be  administered  ? 
It  should  be  inhaled  and  carried  to  complete  narcosis,  but  the  use  of 
chloroform  must  not  cease  when  once  it  has  been  employed.  Inhalation 
should  begin  the  moment  the  nervous  excitement  commences  before  the 
attack;  it  should  be  given  rapidly  in  order  to  get  complete  ana?thesia  as 
soon  as  possible.  This  once  obtained,  the  inhalations  should  not  be  given 
up,  but  should  be  continued  for  several  hours,  six,  eight,  twelve,  fifteen 
hours  or  even  more  if  iieoessary.  If  the  attacks  are  far  apart,  the  amount 
of  chloroform  may  be  diminished  or  suspended  altogether  during  the  in- 
terval. Do  not  allow  the  patient  to  come  out  of  the  chloroform  and 
regain  consciousness;  at  the  least  sign  of  a  return  of  an  attack  give  the 
chloroform  again  to  complete  anaesthesia.  Tarnier,  in  one  case  which  he 
cured,  kept  the  patient  under  chloroform  all  night,  and  6000  grains  of 
chloroform  were  used.  When  once  complete  aneesthesia  is  produced, 
keep  it  up  without  regard  to  time.  This  is  well  in  theory,  but  it  cannot 
always  be  done  in  practice;  for  there  are  cases  in  which  the  use  of  chloro- 
form must  be  suspended  after  a  certain  time,  although  it  need  not  be 
given  up  altogether,  as  in  our  patient. 

It  is  well  then,  to  resort  to  other  means;  but  in  general,  it  is  astonish- 
ing to  see  with  what  ease  patients  will  endure  a  long- continued  anaesthe- 
sia, and  the  length  of  time  that  they  can  be  kept  under  its  influences 
without  inconvenience.  There  is  still  one  other  difficulty,  i.e.,  how  is 
one  to  know  the  exact  time  when  it  will  be  safe  to  give  up  chloroform? 
This  cannot  be  fixed  exactly.  It  is  not  rare  to  have  the  interval  between 
the  attacks  last  for  several  hours,  and  we  seem  to  have  mastered  it,  when 
in  reality  there  has  been  a  short  suspension.  The  question  cannot  possi- 
bly be  answered  absolutely.  When  the  patient  has  gone  several  hours 
without  an  attack,  it  is  best  to  withdraw  the  chloroform  a  little  without 
giving  it  up  altogether.  We  would  keep  the  patient  in  a  half-sleepy  con- 
dition, so  that,  if  necessary,  we  may  produce  by  a  few  inhalations  com- 
plete anaesthesia  if  there  are  any  other  symptoms  of  the  attack.    But  it  is 


DISEASES    OF    PREGNANCY.  139 

only  after  some  time  that  the  chloroform  can  be  entirely  given  up. 
Bailly  goes  still  further,  and  advises  in  cases  in  which  the  attacks  con- 
tinue, and  with  greater  obstinacy,  not  to  keep  up  the  chloroform  more 
than  twelve  hours  at  once,  but  to  stop  it  at  the  end  of  this  time,  to  allow 
the  blood  to  become  purified,  and  to  make  use  of  chloroform  again  in  case 
of  a  relapse.  We  do  not  accept  this  view,  because  we  think  that  chloro- 
form acts  only  on  condition  that  its  influence  is  prolonged,  and  therefore 
it  must  be  given  continuously.  Admitting  the  action  of  chloroform  on 
the  nerve  centres,  we  believe  that,  in  acting  as  Bailly  would  have  us, 
patients  would  be  exposed  to  all  the  dangers  of  chloroform  without  deriv 
ing  any  advantage  from  it. 

But  there  is  another  agent,  little  known,  or  better,  little  used  until 
1872,  which  has  since  taken  a  prominent  place  in  the  treatment  of  eclamp- 
sia, and  we  have  reported  already  some  marvellous  cases  in  which  it  haa 
been  employed.  This  is  chloral-hydrate.  The  use  of  chloral-hydrate  in 
the  treatment  of  eclampsia  either  by  the  mouth,  rectum  or  subcutane- 
ously,  only  dates  back  a  few  years.  It  is  only  since  1809  that  chloral  has 
really  taken  its  place  in  practice  in  the  treatment  of  eclampsia. 

Employed  for  the  first  time,  in  1869,  by  Saint  Germain,  it  was  not 
slow  in  taking  its  place  in  obstetric  practice,  and  we  limit  ourselves  to  the 
following  works  on  the  subject:  Lecacheur,  1S70;  Alexander,  Sedywick, 
Demarquay,  1870;  Campbell,  Milne,  Flok,  Mackintosch,  1870-71;  Ray- 
mond, Furley,  Stearly,  Mac  Eae,  Bookley,  1871-72;  Windhorn,  Mawsell, 
Phillips,  Tarnier,  Bourdon,  Charpentier,  lS72;Franco-y-Mazora,Pelissier, 
1873;  Fanny,  1874;  Beliere,  Chouppe,  1876;  Tesfcut,  1877;  Troquart,  1877, 
Delannay,  1877;  Pelissier,  1878;  Tucoulat,  Froger,  1879.  Fanny,  in  1874; 
collected  36  cases,  16  of  which  had  been  given  chloral  after  other  treat- 
ment, and  20  had  received  chloral  alone.  The  following  results  are 
given : 

Cases.  Cures.  Deaths.  Unknown.  Percent. 
Chloral  given  after  other  treatment,   16         14         2  0  13.5 

"    alone,         ...   20         19  1 

Women  treated  by  chloral  alone,      .36         33         2  1 

Mortality,  ....  3.7 

Chouppe  has  had  good  results  from  chloral,  and  adds  one  cure.  Legroux, 
always  a  partisan,  reports  some  cases  of  death  by  an  over-dose  of  chloral. 
Depaul  reports  3  deaths,  and,  without  giving  np  chloral,  is  but  little  in 
favor  of  it.  Lissonde  rejects  it  entirely;  but  the  best  and  most  interest- 
mg  papers  on  the  subject  are  those  of  Delaunay  and  Testnt,  1877,  and  a 
paper  by  Froger  in  1879. 

Testut  admits  two  kinds  of  eclampsia;  the  one  from  reflex  irritation, 
and  the  other  from  cerebral  cedema.  "In  the  first,  chloral  is  all  |)Owerful; 
(ft)  in  quieting  thespi  alnerve-centresin  which  arises  all  the  muscular  and 
motor  excitement;  (5)  in  paralyzing  the  vaso-motor  centre  in  the  medulla. 


140  A    TREATISE    ON    OBSTETRICS. 

it  tlms  renders  tlie  contraction  of  the  vessels  impossible,  and  also  the  ap- 
pearance of  ana?niia  of  the  convulsive  areas,  and  opposes  at  the  same  time 
ontward  manifestations  of  eclampsia/'  In  eclampsia  due  to  cerebral 
oedema,  chloral  would  be  powerless. 

Delaunay  admits  that  chloral  acts  on  the  nerve-centres  themselves: 
"  The  blood  being  unable  to  stimulate  the  centres  regularly,  produces,  in 
some  way  or  other,  a  general  irritation,  which  leads  to  an  eclamptic  attack 
more  or  less  long,  which  may  or  may  not  be  repeated.  Is  this  central-nerv- 
ous irritation  due  to  cerebral  congestion,  to  serous  exudation  into  the 
ventricles  and  meninges  of  the  brain,  to  oedema  of  the  brain  substance, 
or  to  an  alteration  in  the  nerve  tissue  itself  ?  We  do  not  know.  In  any 
event,  if  other  lesions  do  exist,  it  is  not  on  these  that  the  influence  of 
chloral  is  exerted.  Its  action  must,  of  necessity,  be  exerted  on  the  nerve- 
cells  themselves,  particularly  on  the  nerve-cells  of  the  spinal  cord,  which 
all  regard  as  the  seat  and  origin  of  all  convulsive  attacks  of  whatever  kind. 
Chloral  acts  first  as  an  hypnotic,  and  then  stupifies  the  cerebral  nerve-cen- 
tres, and  m.akes  them  insensible  to  the  cause  of  the  attack." 

Froger  has  collected  all  the  cases  since  1879,  i.e.,  110  cases,  in  51  of 
which  chloral  Avas  alone  used,  with  49  cures  and  2  deaths — 4  per  cent. 
Finally  Testut,  who  has  taken  the  statistics  from  our  table  and  observa- 
tions, gives  the  following  table,  which  comprises  the  results  obtained  from 
different  methods  of  treatment. 


Mortality. 

1.  Eevulsive  treatment. 

. 

50  per  cent. 

2.  Blood-letting   "                 .     . 

■         .         •         • 

35 

8.   Purgative 

.         .         . 

56 

4.  Blood-letting  and  purgative  treatment,     . 

17.3      " 

5.   Anesthetic  treatment, 

17.8      " 

6.   Surgical              " 

29.7      " 

7.   Chloral  alone, 

4.0      " 

8.  Chloral  and  bleeding, 

9.01    " 

9.  Chloral  and  other  treatment^ 

13.32    '' 

The  general  or  average  result  of  the  chloral  treat- 

ment, 

* 

8.49    '' 

Admitting  even  that  a  certain  number  of  fatal  cases  have  not  been  pub  - 
lished,  the  results  given  by  chloral  differ  so  much  from  those  given  by 
other  methods,  that  they  cannot  be  but  striking,  and  Beliere  was  right  in 
saying,  in  1876,  when  speaking  of  our  work  of  1872,  that  perhaps  later 
we  would  give  a  more  decided  opinion.  Since  that  time^  indeed,  cases 
have  increased  and  are  multiplying  every  day,  and,  in  our  opinion,  the 
treatment  of  eclampsia  to-day  may  be  summed  up  in  two  great  classes: 
1.  To  bleed  the  patient  moderately;  2.  To  give  chloral  in  large  doses,  as 
we  shall  show. 

Before  studying  the  different  methods  of  giving  chloral,  let  us  say  that 
Bourdon  is  not  satisfied  with  giving  chloral  when  the  eclamptic  attack  is 


DISEASES    OF   PREGNANCY.  141 

in  full  force,  but  he  has  employed  it  as  a  prophylactic  agent  in  an  albu- 
minuric condition.  In  these  cases  chloral  was  given  in  doses  of  60  grains 
at  the  time  of  confinement,  and  the  labor  has  ended  without  eclampsia. 

llow  and  in  what  dose  should  chloral  be  given?  Chloral  may  be  given 
by  the  mouth,  by  the  rectum,  subcutaneously,  or  by  intravenous  injec- 
tion. Of  these  four  ways,  there  are  two  which  we  discard  at  once,  i.e.,  1st. 
the  intravenous  injections,  because  they  are  dangerous,  and  therefore 
should  not  be  employed  except  as  a  last  resort.  2d.  Subcutaneous  injec- 
tions, because  the}^  expose  the  patiejit  to  abscesses,  phlegmon,  gangrene. 
There  remains  then  the  mouth  and  rectum.  But  eclamptic  cases,  besides 
that  they  swallow  with  difficulty,  vomit  often  all  that  they  take.  This 
would  leave  the  rectum  for  the  administration  of  chloral. 

Bourdon  begins  with  60  grains  of  chloral,  then  he  gives  15  to  30  grains 
every  quarter  of  an  hour,  until  150  grains  have  been  given.  If  the  attacks 
do  not  cease,  he  waits  some  time  before  continuing  the  treatment. 
Chouppe  goes  as  high  as  180  grains.  Testut  at  first  gives  60  grains,  then 
15  grains  every  hour  until  the  enema  is  used  up.  The  enema  is  made  of 
150  grains  of  chloral  and  5000  grains  of  distilled  water. 

Our  method  differs  slightly.  At  first  we  give  60  grains  to  our  patient; 
if  this  is  not  retained  or  only  partially,  we  give  immediately  a  second, 
and  if  necessary  a  third  until  the  medicine  is  borne.  Whether  the  at- 
tacks continue  or  cease,  we  do  nothing  for  a  few  hours,  say  five  or  six  if 
necessary,  and  it  is  only  at  the  end  of  this  time  that  we  give  another  60 
grains  of  chloral. 

It  is  rare  that  we  have  to  pass  this  limit,  which  represents  ^80  grains  of 
chloral,  to  be  taken  in  eighteen  or  twenty-four  hours.  We  do  not  fear  to 
give  a  still  larger  dose,  and  in  one  case  we  have  given  as  high  as  240 
grains  in  twenty-four  hours.  If  the  attacks  become  farther  apart,  we 
make  the  interval  between  giving  the  medicine  longer;  if,  on  the  contrary, 
the  attacks  persist,  we  do  not  wait  as  long.  In  one  case  which  was  cured, 
(by  bleeding  and  chloral)  we  gave  without  inconvenience,  180  grains  of 
chloral  in  10  hours.  We  never  stop  the  medicine  suddenly,  but  we  give 
the  patient  always,  even  when  cured,  60  grains  of  chloral  at  the  end  of 
the  first  twenty-four  hours  after  the  attack.  By  separating  the  doses, 
and  giving  them  in  large  quantities,  we  obtain  greater  quiet  with  less 
trouble  and  worry  to  our  patients.  We  have  never  had  to  exceed  this 
dose,  but  we  would  not  hesitate  to  do  so  if  necessary,  even  to  go  as  high 
as  300  grains,  as  Delaunay  and  Froger  have  done. 

Does  disturbance  of  cardiac  innervation  and  organic  heart-trouble  cen- 
tra-indicate the  administration  of  chloral,  as  G-ubler  would  have  us  be- 
lieve? The  cases  of  Liebreich,  of  Davreux,  of  Waters,  of  Dunlap,  of 
Meldola,  of  Smalmann,  seem  to  justify  this  view.  But  Waters,  Ogles, 
Peyers,  Westrangle  have,  in  spite  of  cardiac  trouble,  had  good  results  from 
chloral.     The  cases  of  Lucas  Championniere  seem  to  justify  these  authors. 


142  A   TKEATISE   ON    OBSTETRICS. 

for  not  only  does  he  not  fear  to  use  chloral  in  patients  who  have  cardiac 
disease,,  but  he  does  not  even  see  any  contra-indication  to  chloroform  in 
cardiac  disease. 

In  all  of  his  surgical  operations,  Lucas  Championniere  uses  chloroform, 
whatever  be  the  state  of  the  patient's  heart,  and  he  has  never  had  an  acci- 
dent. It  is  true,  that  in  these  cases  the  prolojiged  action  of  chloroform 
is  less  than  that  of  chloral.  These  facts,  nevertheless,  are  very  encourag- 
ing, but  we  will  still  resort  to  chloral  only  in  these  cases,  although,  per- 
haps in  smaller  doses. 

2.  Obstetrical  Treatment,  — All  accoucheurs  are  agreed  on  this  one  point, 
that, whenever  one  can  terminate  the  labor  either  by  the  use  of  forceps  or 
by  turning  without  injury  to  the  mother,  it  will  be  best  to  do  so,  as  well 
for  the  mother  as  the  child,  i.e.,  whenever  the  cervix  is  dilated  or  dilatable. 

Depaul  goes  still  further  when  he  says,  "  if  the  cervix  is  already  dilated, 
although  insufficiently,  and  the  child  living,  there  is  reason  to  fear  that 
in  the  new  attack  the  child  may  die.  Auscultation  will  enable  us  to 
foresee  this  by  the  disturbances  in  the  foetal  circulation.  If,  at  the  same 
time,  labor  goes  on  slowly,  if  the  cervix  is  rigid,  the  hope  of  saving  the 
child  would  warrant  a  more  active  interference  and  furnish  an  indication 
for  lateral  incisions  of  the  cervix. '^ 

But  when  the  cervix  is  neither  dilated  nor  dilatable,  when,  in  a  word, 
labor  has  not  commenced,  ought  one  to  artificially  induce  labor  ?  Authors 
are  far  from  agreeing  on  this  subject.  While  Kiwisch,  Hoist,  Wieger, 
Grrenser,  Litzmann,  Stoltz,  Simon,  Thomas,  Schillinger,  Legroux,  Braiin, 
declare  that  the  prompt  evacviation  of  the  uterus  is  of  the  greatest  impor- 
tance in  the  treatment  of  eclampsia,  and  that  it  is  necessary  to  induce  it 
as  rapidly  as  possible,  in  cases  in  which  labor  has  not  already  come  on; 
others,  with  Tarnier,  Busch,  Bailly,  accept  the  induction  of  labor  only 
under  certain  circumstances,  and  have  recourse  to  it  only  when  the 
medical  treatment  has  failed  absolutely,  and,  in  spite  of  the  convulsions, 
the  labor  does  not  come  on  spontaneously.  Finally,  P.  ,  Dubois,  Pajot, 
Blot,  Depaul^  discard  it  entirely.  We  ally  ourselves  with  those  who  hold 
this  last  opinion.  Our  reasons  are  as  follows:  1.  Eclampsia  is  only  a 
symptom  of  a  general  disease  which  the  emptying  of  the  uterus  cannot 
eradicate  at  once.  2.  In  a  good  many  cases  not  only  do  the  convulsions 
continue  after  labor,  but  even  they  are  produced  after  confinement.  3. 
Eclampsia  is  an  acute  disease,  rapid  in  its  course,  and  the  time  required 
for  the  induction  of  labor  surpasses  often  the  duration  of  the  eclampsia. 
4.  When,  on  the  contrary,  labor  does  come  on,  on  account  of  the  eclamp- 
sia itself,  it  progresses  rapidly,  and  allows  generally  of  some  interference 
without  danger  to  the  mother.  5.  All  irritation  in  or  around  the  uterus 
is  sufficient,  sometimes,  to  cause  a  convulsion;  much  more  so  will  it  be 
the  same  with  processes  which  are  employed  to  induce  labor.  If  we  for- 
mulate these  objections,  and  if  we  discard  the  artificial  induction  of  labor. 


DISEASES    OF   PEEGNANCY.  143 

witli  how  much  greater  reason  should  we  reject  forced  delivery.  Of  this, 
there  cannot  be  question  in  any  case. 

But  to  these  theoretical  reasons  we  can  add  others  which  result  from 
figures  collected  in  our  article.  Thus:  in  12?  cases  the  attacks  have  come 
on  before  labor  in  105  cases,  and  they  have  continued  in  spite  of  delivery, 
or  they  have  come  on  only  at  this  period,  in  75  cases.  Of  75  cases  at  the 
Maternity,  in  38  cases  the  attacks  have  persisted,  or  were  produce  1  after 
delivery.  In  297  cases,  155  of  them  have  had  the  attacks  continue  or  ap- 
pear after  labor,  i.e.,  in  a  total  of  478  cases,  278  times  the  attacks  have 
continued  or  were  produced  after  delivery,  i.e.,  in  more  than  half  of  the 
cases.  We  do  not  then  believe  in  the  absolute  efficacy  of  labor  in  puer- 
peral eclampsia;  therefore  we  discard  the  induction  of  labor. 

If  now  we  resume  the  therapeutic  indications  of  eclampsia,  they  may 
be  stated  as  follows:  1.  Albuminuria  once  established,  put  the  patient 
at  the  beginning  on  a  milk  diet,  bleeding  if  necessary  beforehand  to  the 
extent  of  4500  or  6000  grains  without  going  beyond  this  limit;  2.  If  this 
preventive  treatment  fails,  and  if  eclampsia  develops,  venesection  must 
be  performed  and  from  ten  to  sixteen  ounces  of  blood  withdrawn.  An 
enema  containing  from  one  to  four  drachms  of  chloral  should  be  given, 
and,  if  necessary,  during  the  paroxysm  a  few  inhalations  of  chloroform; 
3.  If  labor  begins,  it  is  to  be  terminated  as  quickly  as  possible  by  forceps  or 
version.  We  must,  however,  await  the  dilatation  of  the  cervix.  In  excep- 
tional cases  the  cervix  should  be  incised  if  the  child  is  alive  and  the  at- 
tacks continue  unabated;  4.  Premature  labor  is  never  to  be  induced,  and 
still  less  abortion;  5.  For  'post-partum  eclampsia  give  chloral,  and,  if 
necessary,  chloroform  during  the  paroxysms. 

COIS'VULSIOXS   XOT    DUE    TO   ECLAMPSIA. 

Puevperal  Convulsions. — Besides  eclamptic  convulsions,  we  find  numer- 
ous cases  referred  to  in  literature,  as  puerperal  convulsions.  These  are 
convulsions  occurring  in  the  puerperal  state,  and  differ  essentially  from 
true  eclampsia.  Thus,  Jacquemier,  uuder  the  heading  convulsions  with- 
out determinate  form,  cites  Baudelocque^s  case  of  a  woman  who  fell  into 
convulsions  whenever  her  child  moved.  Deneux  saw  a  woman  who,'  im- 
mediately after  conception,  was  seized  with  spasms  of  the  whole  left  side. 
These  spasms  lasted  without  pain  or  functional  derangement  until  the 
third  month  of  pregnancy.  Eesidence  in  the  country  afforded  relief  in 
three  weeks.  Dubois  saw  a  woman,  pregnant  between  five  and  six 
months,  whose  abdominal  muscles  contracted  so  violently  as  to  force  the 
uterus  completely  down  into  the  pelvis.  The  organ  then  quickly  re- 
turned to  its  place,  rebouading  like  an  elastic  ball.  Other *little  promi- 
nences, apparently  due  to  spasmodic  contractions  of  the  viscera  and  of  the 
abdominal  walls,  appeared  in  the  loins,  the  epigastrium  and  the  umbilical 


144  A   TEEATISE    ON    OBSTETRICS. 

region.  This  woman  recovered  without  au  abortion.  Velpeau  cites  an 
analogous  case.  Delamotte  has  seen  convulsions  from  retention  of  the 
urine.     Hysteria,  tetanus  and  catalepsy,  may  occur  during  pregnancy. 

Neuralgias. 

These  are  common  in  pregnancy.  The  most  frequent  form  is  dental 
neuralgia,  upon  which  Lindner  has  recently  written  at  length.  It  is  one 
of  the  early  symptoms  of  pregnancy,  but  puerperal  tooth-ache  is  not  always 
purely  neuralgic;  it  is  often  due,  as  Pinard  says,  to  gingivitis  or  even  to 
"caries.  In  these  cases  the  teeth  should  not  be  extracted,  but  local  meas- 
ures relied  on. 

Pregnant  women  are  also  often  the  victims  of  migraine,  head-aches, 
cramps,  pains  in  the  legs  and  of  intercostal  neuralgia.  They  often  have 
hepatalgia,  Avith  or  without  biliary  calculi.  We  have  seen  hepatalgia  with- 
out calculi  repeated  in  the  same  patient  in  three  consecutive  pregnancies. 
Vv"e  have  also  recently  seen,  with  Dr.  Magnin,  a  case  of  inflammation  of  the 
gall-bladder,  which  ended  in  eight  days,  without  inducing  premature 
labor.  We  have  seen  six  cases  of  hepatic  colic,  either  during  utero-gesta- 
tion  or  during  labor.  In  neither  of  them  was  pregnancy  interrupted. 
Quinine  best  relieves  these  neuralgias,  but  they  are  very  rebellious,  and 
only  stop  after  a  certain  stage  of  pregnancy.  Morphine,  hypodermically, 
has  rendered  us  some  service.  Neuralgias  of  the  legs  are  most  persistent, 
and  sometimes  do  not  disappear  until  after  labor.  Duprilot  classifies 
neuralgias  as  follows: 

1.  Nervous  Troubles  from  mecJianical  Causes. — Abdominal  Pains. — 
These  correspond  nearly  to  the  points  of  exit  of  the  lumbo-abdominal  and 
sacral  plexuses.  Pectoral:  at  the  waist  or  near  the  insertions  of  the  ab- 
dominal muscles.  Lumbar  or  inguinal:  not  very  serious;  sometimes 
prodromata  of  abortion.  Crural:  numbness  and  cramps.  Uterine: 
uterine  rheumatism. 

2.  Nervous  Troubles  of  central  Origin. — They  are  due  to  an  alteration 
of  the  blood,  or  to  a  direct  action  of  the  blood  on  the  nerve  tissue.  A. 
Abnormal  distribution  of  blood  due  to  pregnancy.  1.  Whenever  there 
is  a  determination  of  blood  to  one  organ  the  others  suffer  from  lack  of 
blood.  Compression  of  large  abdominal  veins  by  the  foetus.  B.  Abnormal 
composition  of  the  blood,  during  pregnancy.  Plethora;  anemia.  In  the 
head:  ringing  in  the  ears;  disturbances  of  the  senses;  muscse  volitantes; 
irritability;  change  of  disposition;  vertigo;  insomnia;  headache.  In  the 
chest:  palpitations;  syncope;  dyspnoea.  In  the  stomach:  anorexia;  dyspep- 
sia; gastralgia.  Various  sensory  derangements.  C.  Depreciation  of  blood 
by  abnormal  substances.     Albuminuria. 

3.  Reflex  Troubles. — Tetanic,  apoplectiform,  hysterical,  epileptic  and 
eclamptic  convulsions;  emesis;  cough;  spasms;  reflex  vesical  irritability; 
vascular  spasms;  spasms  of  the  capillaries;  hemiplegia;  paralysis. 


DISEASES    OF   PREGNANCY.  145 

Vertigo,  SjMr/cs  before  the  Byes,  Syncope. 
Syncope  is,  certainly,  the  most  frequent  of  these  accidents,  is  inde- 
pendent of  cardiac  affections,  and  occurs  from  insignificant  or  from  inde- 
terminate causes.  It  may  be  produced  by  emotion,  joy,  anger,  fright, 
strong  odors,  repugnance  for  objects  or  persons,  or  movements  of  the 
child.  Often  it  occurs  at  ;neals,  but  most  often  when  the  horizontal  posi- 
tion is  exchanged  for  a  vertical  one.  Ordinarily  occurring  without  precur- 
sory symptoms,  syncope  may  be  preceded  by  yawning,  malaise  and  prae- 
cordial  heat,  but  almost  never  induces  complete  loss  of  sensibility  and 
intelligence.  Generally  short,  syncope  may  still  be  protracted,  and  is  then 
often  accompanied,  as  Cazeaux  remarks,  by  hysterical  symptoms,  such  as 
oppression,  hypogastric  pain,  constriction  of  the  throat,  and,  sometimes, 
true  convulsions.  The  best  treatment  is  to  stretch  the  patient  out  flat, 
with  the  head  low,  and  then  to  employ  tonics  and  antispasmodics.  These 
purely  nervous  accidents  are,  generally,  devoid  of  gravity,  and  do  not  dis- 
turb the  regular  course  of  pregnancy. 

Puerperal  Paralyses. 

Paralysis  may  supervene  during  pregnancy  or  after  delivery,  as  is  the 
case  with  eclampsia.  Hence  their  designation  by  the  generic  term,  puer- 
peral paralyses.  As  the  older  writers  especially  noticed  these  paralyses 
after  labor,  they  referred  them  to  the  two  great  theories  then  dominating- 
puerperal  pathology,  retention  and  suppression  of  the  lochia,  and  milk 
metastases.  These  paralyses  are  now  better  studied,  and,  having  ascer- 
tained that  they  occur  during  pregnancy,  we  have  been  forced  to  attribute 
them  to  another  source.  These  paralyses  are  very  varied  in  their  mani- 
festations, although  they  affect,  particularly,  three  leading  forms.  There 
may  be  hemiplegias  or  paraplegias,  which  are  complete  or  incomplete,  local 
or  general,  i.e.,  affecting  one  limb  or  both  limbs,  on  the  same  or  on  op- 
posite sides.  The  paralysis  may  be  limited  to  the  face,  or  affect  the  face 
and  the  limbs;  it  may  particularly  involve  some  one  organ  of  sense  or 
one  part  of  the  muscular  or  nervous  system,  but  there  is  always  a  marked 
tendency  toward  hemiplegia  or  paraplegia. 

By  complete  paralysis  We  understand  the  forms  in  which,  if  the  case  be 
one  of  hemiplegia,  the  upper  and  lower  limbs  of  the  same  side  are  both 
involved,  or,  if  paraplegia  be  present,  both  lower  extremities  are  impli- 
cated. The  term  partial  paralysis  is  reserved  for  the  cases  in  which  a  sin- 
gle limb  is  attacked.  Among  these  paralyses  there  is  one  special  variety 
observed  only  after  labor.  This  is  the  traumatic  paralysis  seen  after  diffi- 
cult labors,  with  or  without  surgical  intervention,  and  to  which  we  com- 
pare the  palsies  of  newborn  children  extracted  by  the  forceps  or  by  version. 

Frequency. — Although   not  extremely  frequent,  paralysis   is  not  very 
rare  for,  in  our  monograph  of  1872,  we  had  already  collected  149  cases, 
thus  classified:     Hemiplegias,   57;  paraplegias,  25;  traumatic  paralyses. 
Vol.  II.— 10. 


146  A   TREATISE    ON    OBSTETEICS. 

12;  partial  paralyses,  21;  paralyses  of  the  senses,  34;  total  149.    We  will 
now  study  these  different  varieties. 

Hemiplegia. 

The  first  and  by  far  the  most  frequent  form  of  puerperal  paralysis  is 
hemiplegia.  Out  of  one  hundred  and  forty-nine  cases  of  paralysis,  we 
found,  in  1872,  fifty-seven  hemiplegias.  Five  years  later,  Darcy  quoted 
ten  new  examples,  and  since  then,  all  authors  who  have  paid  attention 
to  this  question  have  published  new  cases. 

The  causes  are  numerous.  Aside  from  the  two  old  theories, retention  and 
suppression  of  the  locliia,  and  milk  metastases,  which  could,  at  the  best,  only 
be  applied  to  the  explanation  of  paralyses  occurring  after  labor, we  mention: 

1.  Cerebral  hemorrhage,  cited  in  1848,  by  Meniere,  who  particularly 
insists  upon  the  hypertrophy  of  the  left  ventricle  and  plethora.  Darcy 
admits  three  forms:  a.  Apoplectic,  in  which  the  apoplexy  is  often  so  pro- 
found that  the  existence  of  hemiplegia  can  not  be  ascertained,  b.  Mixed 
form.  Consciousness  lost,  but  only  for  a  short  time,  and  eclampsia  may  or 
may  not  have  preceded.  This  is  not  genuine  apoplexy,  c.  Paralytic  form. 
In  these  cases  there  is  hemiplegia  lasting  at  least  several  months,  and  un- 
dergoing a  gradual  cure.     d.  Pregnancy  occurring  in  hemiplegic  women. 

2.  Cerebral  Congestion. — This  is  particularly  induced  by  the  efforts  of 
labor  or  by  eclampsia.  It  produces  torpor,  slight  or  well-marked,  after 
which  more  or  less  complete  hemiplegia  remains  and  disappears,  ordina- 
rily, quite  rapidly. 

3.  Cardiac  Affections. — Endocarditis. — This  may  be  the  acute,  ulcera- 
tive, typhoid  or  pyohasmic  form  of  Senhouses  Kirke,  Simpson,  Hardy, 
Charcot,  Peter,  Bucquoy,  Martineau,  and  Decorniere,  or  the  subacute 
and  chronic  form  of  OUivier,  to  which  recent  researches  on  puerperal  car- 
diac troubles  lend  new  importance.  Attacking  by  preference  the  mitral 
valve,  as  does  rheumatic  endocarditis,  it  advances  progressively  and  in- 
creases with  the  number  of  pregnancies.  Causing  the  growth  of  valvular 
vegetations,  it  may  give  rise  to  cerebral  embolism.  In  this  connection  we 
should  mention  the  arterial  thromboses  reported  by  Oke,  Risdon,  Ben- 
net,  Turner  and  Simpson.  This  last  author  divides  them  into  five  kinds 
caused  by:  a.  The  detachment  of  old  or  organized  cardiac  concretions 
and  their  transportation  into  arterial  channels.  b.  Entrance  into  the 
circulation  of  recent  coagula  formed  in  the  heart  or  in  the  great  arteries. 
c.  Local  arteritis,  d.  A  lesion  of  the  tunica  intima  of  the  arteries,  e. 
Foreign  bodies  coming  from  the  veins  and  lodged  in  the  pulmonary  artery 
or  its  divisions. 

4.  Alterations  in  the  Blood. — These  changes  |)lay  the  leading  role  in 
producing  endocarditis,  acute  or  sub-acute,  and  arterial  thrombosis. 
Hemiplegia  is  thus  only  the  epiphenomenon  of  a  cardiac  affection  devel- 
oped during  pregnancy,  or  after  numerous  pregnancies,  and  reacting,  in 
turn,  on  the  central  organ. 


DISEASES    OF    PREGISrANCY. 


147 


5.  Alhuminuria. — Cases  Imve  been  repoi-ted  by  Fleetwood  Cliurchill^ 
Latham,  "Romberg,  Simpson,  Lever,  Imbert  Goiirbeyre,  Johnson,  Braiin, 
Foiirnier,  etc. 

6.  Puerperal  Septicce-mia.  —  Hervieux  and  Charpentier,  have  reported 
cases. 

7.  Anoemia. — Stork,  Bataille,  Ley,  Churchill,  Laurent. 

8.  Reflex  Action. — Whyt,  Prochaska,  Lever,  Churchill,  Imbert  Gour- 
beyre,  Pellegrini,  Crosse  and  Stokes,  have  reported  cases. 

The  last  two  causes  cannot  be  absolutely  eliminated,  but,  in  reality, 
two  grand  causes  seem  to  us  to  dominate  the  pathogeny  of  puerperal 
hemiplegia.  First,  cerebral  lesions,  congestions,  hemorrhages,  thrombo- 
ses of  the  sinuses,  whether  primary  (Meniere)  or  secondary,  lead  to  cardiac 
affections,  i.e.,  to  the  acute  puerperal  endocarditis  of  Simpson  and  Decor- 
niere,  or  to  OUivier's  sub-acute  progressive  endocarditis,  or  to  puerperal 
cardiac  disturbances  (Peter,  Marty,  Berthiot  and  Porak).  These  affec- 
tions act,  in  turn,  either  rapidly  or  slowly,  in  determining  the  sudden  or 
the  slow  development  of  hemiplegias.  Second,  we  place  albuminuria  with 
or  without  eclampsia.  We  place  last,  as  quite  subordinate,  and  perhaps, 
doubtful,  anaemic  hemiplegias,  as  well  as  those  due  to  reflex  action  and 
to  puerperal  septicgemia. 

Frequency. — Although  not  rare,  puerperal  paralyses  are  not  very  fre- 
quent, but  it  is  impossible  to  furnish  reliable  statistics,  since  many  cases 
pass  unobserved,  owing  to  the  coexistence  of  coma.  The  age  of  the 
patients  does  not  seem  to  have  a  great  influence,  for,  although  there  are 
more  cases  between  twenty-five  and  thirty  years,  this  is  the  age  at  which 
women  generally  become  pregnant.  Our  outside  figures  were  eighteen 
and  forty-five  years.  Darcy  gives  twelve  and  forty-five  years.  Among 
thirty- five  of  our  cases,  twenty- four  women  were  from  eighteen  to  thirty 
years,  and  fourteen  from  thirty-two  to  forty-five  years.  Among  thirty- 
six  of  Darcy's  cases,  twenty-one  were  less  than  thirty  years,  and  fifteen 
were  from  thirty  to  forty-three  years.  The  same  obtains  as  regards 
primiparse  and  multipara.      Our  statistics  are  thus  as  follows: 


Charpentier. 
Primiparge,       .         .         .17 
Multipar^e,        .         .         .14 

Primiparge, 
Multiparge, 

Darcy. 

.  15 
.     17 

ch  may  be  thus  classified: 

1st  pregnancy, 
2d 

.     17 
1 

1st  pregnancy, 
2d 

.  15 
.     3 

3d 

.       8 

3d 

.     3 

4th       " 

4th 

.     2 

5th       " 

5th 

.     2 

6th       " 

6th 

o 

7th       " 

10th 

.     1 

10th       " 

13th 

.     3 

Before 

.     3 

148 


A    TREATISE    ON    OBSTETRICS. 


Time  of  appearance. 
Hemiplegias  before  pregnancy, 
''  during         " 

"        labor 
"  after  delivery, 

"  not  stated, 

Charpentier. 
1st  month, 
3d 
2d 

3d  month, 
4th      " 
5th       ''■ 
6th       '•' 
7th       '^ 

7th  and  -J  months, 
8th  month,     . 
8th  and  ^  months, 
9th  month,     . 


Charpentier.      Darcy. 


3 

19 

1 


2 
2 

1 
1 
1 
1 
1 

1 
1 

4 

15 


Darcy. 
1st  month, 
2d       '' 

2d  and  ^  months, 
3d  month, 
4th  " 
5th  " 
6th  '■ 
7th  '• 
7th 

8th  month, 
8th  and  ^  months, 
9th  month,     . 


3 
23 

1 
23 


3 

6 
1 

8 
2 
5 

29 


Thus,  it  is  in  the  last  two  months  of  pregnancy  that  hemiplegias  arc 
the  most  frequent.     After  kbor  they  appear,  usually  within  ten  days. 

Hemiplegias  after  Ddivery. 


Charpentier. 

Darc3' 

Almost  immediately  after. 

3 

3 

2  days  after,      .         .         .         ^         „ 

1 

3     "       " 

.                         .                        .                        0                         C 

1 

4     ^'-       '' 

c                                .                               O                               o                               o 

2 

7     "       " 

..... 

1 

8     "       " 

..... 

1 

3 

9     "       " 

•                    e                    •                    ■                    • 

1 

10     "       '' 

o                      •                      e                      .                  '    . 

2 

4 

14     "       " 

1 

15     "       "          ...... 

1 

1 

16     '"       "-          ...... 

1 

One  month  after, 

2 

Six  weeks       " 

1 

As  regards  the  side  on  which  the  hemiplegia  was  located,  Darcy  has 
found:  Eight  hemiplegia,  26;  crossed  hemiplegia,  2;  left  hemiplegia,  IG; 
side  not  stated,  14. 

Signs  and  Diagnosis. — There  may  be  prodromata  or  these  may  be 
absent.  Hemiplegias  due  to  cerebral  lesions  commence,  most  frequently, 
suddenly,  like  an  apoplectic  attack.  In  women  with  albuminuria,  how- 
ever, headache,  disturbances  of  vision,  or  even  convulsions,  generally 
precede  the  attack  by  a  few  hours  or  days.  The  characters  of  the  paralysis 
are  as  follows:  Often  it  developes  quickly,  simultaneously  invading  the 
two  limbs  and  even  the  face.     Often,  also,  the  upper  and  lower  limbs  are 


DISEASES    OF   PREGiSrAlSrcy.  149 

successively  attacked.  Sometimes  the  hemiplegia  is  incomplete^  now 
affecting  the  npper  extremity;,  and  being  accompanied  by  facial  paralysis 
or  amaurosis;  now  attacking  the  lower  limb  of  the  same  or  of  the  opposite 
side;  now  being  limited  to  the  face.  It  simultaneously  involves  motion 
and  sensation,  but  is  rarely  attended  by  vesical  or  rectal  difficulties.  More 
rarely  yet  the  intelligence  is  impaired.  Generally  it  remains  perfect  after 
the  patient  has  recovered  consciousness.  Speech  is,  indeed,  affected,  but 
that  is  due  to  impaired  motility  of  the  tongue,  and,  excepting  in  one  case 
of  our  own,  and  in  two  of  Temoin,  in  which  delirium  persisted  several 
days,  the  intellect  was  unimpaired.  Paralysis  seems  limited,  in  short,  to 
motion  and  to  sensation.  The  lesions  of  motility  are  the  predominating 
features.  Sometimes  there  is  simply  weakness  or  numbness,  accom- 
panied, in  some  cases  by  tremors,  formication,  or  more  or  less  acute  pains 
in  the  limbs  involved.  Sometimes  the  limbs  are  absolutely  motionless 
and  remain  inactive  in  any  i^osition,  without  the  patients  being  able  to 
move  them  at  all.  Mobility  may  be  progressively  restored,  or  even  rap- 
idly, in  a  few  hours  or  days.  Sometimes  the  paralysis  lasts  several  months 
before  absolutely  disappearing.  In  rare  cases,  death  closes  the  scene,  but 
patients  generally  recover,  if  not  entirely,  yet  to  such  an  extent  as  to  re- 
sume some  of  their  occupations.  Disturbances  of  sensibility  present 
greater  variety  than  those  of  motility,  but  exist  habitually.  In  the  major- 
ity of  cases,  motility  is  notably  impaired.  There  may  be  all  kinds  of  an- 
algesias and  of  auEesthesi^e,  which  may  be  the  first  symptoms  of  the  j)a- 
ralysis.  The  patients  notice  that  some  part  of  their  person  first  becomes 
insensible  and  then  immobile.  So  the  two  symptoms,  impairment  of 
movement  and  diminution  of  sensibility,  progress  side  by  side,  sensibility 
generally  returning  sooner  in  cases  resulting  in  a  cure.  This  change  in 
sensibility,  limited  to  the  paralyzed  side,  or  involving  the  other  as  well, 
is  more  or  less  profound,  varies  from  the  mildest  analgesia  to  com|)lete 
anaesthesia,  and  presents  remissions  and  exacerbations  accompanied  by 
sensations  of  cold  or  heat,  without  these  two  agents  locally  applied  pro- 
ducing appreciable  phenomena.  One  may  prick  or  pinch  the  patients 
without  their  knov/ledge.  Again,  there  maybe  real  hjrperssthesia,  always 
attended  by  sensations  of  cold  or  of  heat. 

This  difference  in  the  symptoms,  may  serve  to  farther  facilitate  the 
diagnosis  and  often  reveals  the  source  of  the  paralysis.  Thus,  in  paraly- 
sis from  cerebral  affections,  the  inception  is  always  sudden,  and  the  pa- 
thological conditions  rapidly  reaching  their  maximum,  are  lasting  and 
fatal.  On  the  other  hand,  in  so-called  reflex  paralysis,  the  beginning  is 
insidious.  The  lesions  of  motility,  at  first  consisting  in  weakness  and 
numbness,  gradually  pass  into  complete  hemiplegia.  In  the  former  case 
all  the  extremities  are  almost  always  simultaneously  involved,  while,  in 
the  latter  case,  partial  paralysis  is  often  seen.  Moreover,  in  the  latter 
case,  the  lesions  of  sensibility  are  various,  vfhile,  in  cerebral  lesions,  sen- 


150  A  TREATISE    ON    OESTETKICS. 

sibilityis  usually  just  as  completely  abolished  as  motility.  In  the  variety 
due  to  albuminuria,  there  are  usually  prodromal  symptoms,  viz, ,  headache, 
visual  derangements,  eclampsia,  convulsions.  In  these  cases  constitutional 
symptoms,  fever,  peritonitis,  phlebitis,  and  lymphangitis  are  absent,  al- 
though they  do  occur  in  paralysis  from  puerperal  septicsemia.  These 
hemiplegias  considerably  resemble  those  occurring  aside  from  pregnancy, 
but  the  puerperal  state  impresses  a  certain  stamp  upon  their  course  and  their 
termination.  Puerperal  hemiplegias,  commencing  often  during  the  later 
months,  increase  as  pregnancy  advances,  acquire  greater  intensity  dur- 
ing labor,  and  subsequently  disappear,  either  completely  or  by  gradual 
subsidence.  In  some  cases  the  hemiplegia  does  not  entirely  disappear, 
and  if  several  pregnancies  succeed  each  other,  the  paralytic  symptoms  are 
aggravated  either  at  the  time  of  a  new  conception,  or  during  utero-gesta- 
tion.  In  these  cases  there  is  sometimes  amelioration  of  the  symptoms  in 
the  later  months,  but  during  parturition,  or  some  days  later,  there  is  a 
real  relapse  from  which  the  patient  does  not  recover  for  some  time. 
Again,  in  rarer  instances,  hemiplegia  begins  during  labor,  but  it  is  then 
almost  always  the  result  of  eclampsia,  albuminuria  having  been  super- 
added to  the  influences  due  to  the  puerperal  state.  In  a  third  class  of 
cases,  which  are,  at  least,  as  frequent  as  the  first,  the  paralysis  does  not 
begin  until  after  labor,  and,  strangely  enough,  generally  after  a  natural, 
easy  and  short  confinement. 

Prognosis. — This  is  very  variable,  and  depends  chiefly  upon  the  cause 
producing  the  paralysis.  Hemiplegia  due  to  organic  lesions  is  quite  often 
fatal,  but  the  other  forms  of  hemiplegia  are  not.  Hemiplegias  may  be 
divided  into  two  large  classes:  those  due  to  extensive,  and  those  due  to 
transient  or  slight  cerebral  lesions.  In  fatal  cases,  death  usually  occurs 
very  soon,  within  two  or  three  days,  and  the  autopsy  reveals  considerable 
cerebral  lacerations  and  hemorrhages.  When  death  ensues  more  gradu- 
ally, we  find  meningitis,  or  much  less  important  hemorrhages,  or  a  com- 
bination of  lesions  which  suffice  of  themselves  to  cause  death,  inde- 
pendently of  the  cerebral  affection.  When  recovery  occurs,  it  is  gener- 
ally very  rapid,  taking  place  in  a  few  hours  or  days,  thus  showing  the 
lesion  to  have  been  transient.  In  some  cases,  if  long  protracted,  the  in- 
tellect has  been  impaired.  Death  does  not  occur  so  frequently  as  might 
be  expected.  AVe  find  it  to  have  taken  place  in  twenty  of  our  fifty-seven 
observations.  Another  peculiarity  of  these  hemiplegias  is  that,  in  some 
cases,  before  permanently  disabling  a  limb  or  a  side,  they  may  alternately 
disappear  and  reappear.  This  characteristic  feature  is  not  always  a  proof 
of  benignity,  for  two  such  cases  resulted  fatally.  These  hemiplegias 
exert  hardly  any  influence  upon  pregnancy  and  labor.  The  majority  of 
hemiplegic  women  almost  or  quite  reach  full  term.  Among  fifty-eight 
of  Darcy's  cases,  thirty-two  reached  the  full  term.  In  ten  cases  labor 
occurred  prematurely,  but  this  hardly  happens  except  when  albuminuria 


DISEASES    OF   PEEGNANCY.  151 

is  present.  In  tlie  cases  referred  to,  eclampsia  preceded  labor,  and  the 
paralysis  was  consecutive  to  these  attacks.  In  only  two  or  three  in- 
stances, has  labor  been  slow  and  prolonged.  In  all  the  others  parturition 
was  normal,  easy  and  rapid. 

The  treatment  varies  with  the  cause,  the  nature  and  the  form  of  the 
paralvsis.  Venesection,  friction,  mineral  baths,  strychnia,  and  electricity 
have  been  employed,  sometimes  with  success,  and  sometimes  without 
any  favorable  effect  upon  the  patient's  condition. 

Paraplegias. 

These  are  not  less  frequent  than  hemiplegias,  and  here  we  find,  after 
labor,  the  two  chief  ancient  theories  regarding  suppression  of  the  lochia 
and  milk  metastases.  The  causes  are  numerous,  as  in  hemiplegia^  but 
we  find  here  two  new  and  important  causes;  reflex  action,  Avhicli  we 
admitted  with  some  reserve  as  a  cause  of  hemiplegia,  and  traumatism. 
We  mention,  therefore,  in  the  first  place: 

1.  Paraplegias  from  medullary  Lesions. — In  this  case  the  medullary 
lesion  sometimes  exists  before  conception,  and  pregnancy  only  modifies 
its  original  action.  On  the  other  hand,  the  lesion  may  be  developed  under 
observation  during  pregnancy,  the  physician  thus  witnessing  the  series  of 
morbid  results  terminating  in  death,  and  ascertaining  the  existence  of  the 
lesion,  post  mortem. 

2.  Paraplegias  from  Albuminuria. — Some  authors  admit  this  cause, 
without  reserve,  while  others  regard  it  as  exceptional,  and  still  others  re- 
ject it.  We  reject  it,  in  common  with  Lasegue,  Fournier,  Addison,  See 
and  Hervieux.  Lasegue,  in  the  Archives  de  Med.,  1852,  studying  the 
cerebral  disorders  which  occur  in  Bright's  disease,  mentions  coma,  con- 
vulsions, delirium,  and  disturbances  of  the  senses,  but  insists  upon  the 
absence  of  coma,  in  the  following  terms:  "  The  absence  of  paralysis  and 
the  peculiar  condition  of  respiration  almost  suffice  to  banish  doubt.  No 
matter  at  what  period  of  the  disease  the  case  is  observed,  or  what  the  in- 
tensity of  the  stupor,  we  do  not  find  the  slightest  paralysis.  Whenever 
concomitant  paralysis  is  reported,  it  may  be  referred  to  a  local  cause,  and 
is  not  due  to  Bright's  disease.  Bright  himself  emphasized  this  distinction, 
which  experience  fully  confirms." 

3.  Paralyses  from  reflex  Action. — These  are  the  functional  paraplegias 
of  Jaccoud,  which  were  formerly  called  peripheral  paraplegias.  This  is 
the  prevailing  cause  of  puerperal  paraplegias.  The  relation  between 
paraplegia  and  certain  morbid  conditions  of  the  genital  organs  was  men- 
tioned by  Churchill,  Romberg,  Hunt,  Stanley,  Lisfranc,  Esnaut,  thesis 
1857,  Vallin,  thesis  1858,  and  j^onat.  ISTow,  as  Hervieux  remarks,  "if 
the  diseased  uterus  is  capable  of  producing  paraplegias,  why  may  not  the 
gravid  uterus  or  the  uterus  in  its  post-partum  state,  exert  the  same  patho- 
logical influence  ?  "     Jaccoud  gives  the  name  of  functional  paraplegias  to 


152  A    TREATISE    OjST    OBSTETRICS. 

all  those  wliose  distinctive  feature  is  the  absence  of  all  material  conditions 
producing  paraplegias  of  his  first  three  classes  (spinal  lesions,  ischgemia 
and  dyscrasi^e),  and  he  classifies  functional  paraplegias  as  follows.  1.  The 
paralysis  results  from  a  more  or  less  prolonged  abnormal  excitation  trans- 
mitted to  the  medulla  by  the  peripheral  nerves,  from  the  geni to-urinary 
organs,  the  abdominal  viscera  or  the  skin.  This  is  peripheral  paraplegia, 
2.  Paraplegia  follows  pyrexia  and  acute  diseases.  3.  Paraplegia  appears 
during  the  coma  of  a  constitutional  or  cachectic  disease.  4.  Paraplegia 
developes  from  a  neurosis. 

For  him,  therefore,  puerperal  paraplegia  does  not  belong  among  reflex 
paralyses.  Making  a  careful  distinction  between  the  paralysis  of  pregnancy 
and  puerperal  or  post-puerperal  paralysis,  he  places  the  former  among 
the  paraplegias  due  to  anaemia,  attributing  it  to  chloro-angemia  and  to  a 
nervous  state,  and  the  second  class  of  cases  among  organic  paraplegias, 
from  compression  of  peripheral  nerves,  thus  attributing  a  predominating 
influence  to  traumatism.  Jaccoud,  disputing  the  propriety  of  the  term 
reflex  paralysis,  insists  that  the  paraplegia  is  not  reflex,  but  due  to  the 
contraction  of  the  meduUary  vessels,  and  that  we  should  designate  the 
paralysis  as  paraplegia  by  reflex  vascular  contraction  or  reflex  ischgemia. 
But  he  does  not  even  admit  this  contraction,  for  then  it  should  be  per- 
manent, or  ought,  at  least,  to  last  as  long  as  the  ]3araplegia,  i.e.,  weeks  or 
months,  which  is  contrary  to  all  the  principles  of  nervous  action,  for  pas- 
sive dilatation  tends  always  and  everywhere  to  active  contraction  of  the 
vessels.  If  there  really  existed  a  permanent  ischgemia  of  the  medulla,  the 
organ  ought,  after  a  time,  to  present  the  material  lesions  characteristic 
of  ischgemic  degeneration.  Eejecting,  therefore,  the  opinion  of  Willis, 
Whyth,  Prochaska,  and  Brovvn-Sequard,  he  formulates  the  following 
theory:  "  An  abnormal  excitation  is  transmitted  to  the  medulla  by  the 
sensitive  nerves  of  the  uterus,  the  kidneys,  the  bladder,  the  bowel,  etc. 
It  exhausts,  at  the  end  of  a  variable  time,  the  peculiar  excitability  of  the 
corresponding  region  of  the  organ,  and  the  inertia  of  these  nervous  ele- 
ments under  encephalic  stimulation,  interrupts  the  channels  of  the  motor 
impulses.  The  paralysis  of  all  the  parts  situated  below  the  affected  point 
is  the  necessary  result."  Frog6,  thesis  1868,  admits  that,  in  certain  cases, 
the  gravid  uterus  may  react  upon  the  nervous  centres  by  the  physiological 
phenomena  located  in  it,  to  such  an  extent  as  to  precipitate  disturbances 
of  innervation,  among  which  is  reflex  paralysis.  liervieux  adopts  the 
theory  of  reflex  paraplegia  outright,  and  the  observations  cited  in  our 
own  monograph  seem  to  leave  no  :loubt  on  the  subject. 

4.  Clilo7  o-anoemic  and  posi-hemor9'hagic  Paralyses. — These  two  forms 
of  paralysis  may,  we  think,  be  arranged  under  one  heading,  the  angemic 
paraplegias.  They  embrace  what  Jaccoud  describes  under  the  title  dys- 
crasic  and  ischaemic  paraplegias.  Some  paraplegias  from  dyscrasise  de- 
pend on  a  qualitative  alteration  of  the  blood,  i.e.,  are  produced  by  modi- 


DISEASES    OF    PREG-NANCY. 


153 


fications  in  the  normal  elements  of  the  blood,  as  regards  proportions  and 
quality.  Some  are  due  to  the  presence,  in  the  blood,  of  some  foreign 
substance.  Now,  the  composition  of  the  blood  is  changed  during  preg- 
nancy, and  hemorrhages  occurring  during  or  after  labor,  and  even  during 
pregnancy,  alter  the  blood  by  reducing  its  quantity,  and  thus  themselves 
sometimes  cause  paraplegias. 

5.  Paraplegias  from  Blood-poisoning,  in  puerperal  Septiccemia. — These 
are  admitted  by  Hervieux,  but  Ave  think  that  they  should  be  included 
among  paraplegias  due  to  organic  lesions.  They  are  usually  secondary  to 
inflammatory  lesions,  of  which  they  are  only  the  results. 

6.  Traumatic  Paraplegias, — These  will  be  separately  studied,  and  will 
serve  as  transitional  forms  between  complete  and  partial  paraplegias. 

Frequency. — Paraplegias  seem  less  frequent  than  hemipilegias,  since  we 
found  only  twenty-five  among  our  one  hundred  and  forty-nine  cases. 
They  therefore  bear  to  hemiplegias  the  approximate  relation  of  one  to  two. 

Age. — They  are  encountered,  most  frequently,  between  nineteen  and 
thirty  years,  but  we  have  noted  six  cases  between  thirty-one  and  fifty 
years.     The  number  of  pregnancies  is  indicated  in  only  a  few  of  the  cases: 


1st  pi-egnancy. 

6  cases. 

4th  pregnancy. 

.     1  case 

2d 

.     2     " 

1     6th 

.     1     " 

3d 

.     3     " 

i  10th 

.     1     " 

In  four  cases,  a  paraplegia  which  existed  before  pregnancy,  or  during  a 
preceding  pregnancy,  relapsed  owing  to  conception.  In  the  cases  of  Eiviere 
and  of  Etcheveria,  paraplegia  followed  abortions. 

Time  of  Apipearance. — Like  hemiplegias,  they  may  appear  before  or  dur- 
ing pregnancy  and  during  or  after  labor. 

Paraplegias  existing  before  pregnancy, 
''  beginning  during    " 

"  during  labor,  . 


Paraplegias  after  labor,  14 


Paraplegias  are  thus  much  more  frequent  after  labor  than  during  preg- 
nancy. 

Symptoms  and  Course. — These  paraplegias  do  not  differ  from  those  not 
dependent  upon  the  puerperal  state,  and  may  be  either  complete  or  in- 
complete. There  are  three  types  of  the  latter  variety:  "  1.  The  patient 
cannot  take  a  step,  nor  even  stand  upright,  but,  when  she  is  lying  down. 


2  cases,  six  years  before. 

5     "       at  2,  4,  7,  and  8  mos. 

1  case. 

A  few  hours  after,      1  case. 

31  hours,         .         .     1     " 

7  days, 

1     " 

8     " 

1     " 

11     " 

1     " 

17     " 

1     " 

1  month, 

1     " 

7  months. 

.     1 

Date  not  give 

^1, 

6  cases 

154  A    TEEATISE    ON    OBSTETEICS. 

slie  can  either  move  the  whole  limbs  or  execute  partial  movements.  2. 
The  patient  can  stand  Avithout  support,  and  can  even  take  a  few  tottering 
steps,  but  walks  without  raising  the  feet.  She  executes  this  kind  of 
progression  by  the  alternate  gliding  of  the  whole  Sole  upon  the  ground, 
or  the  heel  being  lifted,  it  is  only  the  anterior  extremity  of  the  foot  which 
glides  along  the  ground.  3.  The  patient  may  sometimes  walk  quite  a 
long  time  without  support,  except  that  of  a  cane,  but  she  feels  early  and 
unusual  fatigue,  which  is,  most  frequently,  not  in  accord  with  the  devel- 
opment of  the  muscular  system.^'     (Jaccoud.) 

These  three  types  generally  succeed  each  other,  the  disease  rarely  sud- 
denly reaching  its  maximum  intensity.  It  is,  at  first,  an  awkwardness 
and  an  enfeeblement  of  the  limbs,  or  of  one  limb,  succeeded  by  complete 
paralysis  after  a  variable  time.  Paraplegia  shows  another  peculiarity  in 
some  case^  It  oscillates,  as  it  were,  in  such  a  way  that  if,  for  example, 
the  left  leg  were  first  attacked,  the  right  leg  would  be  in  turn  affected 
after  a  few  hours  or  days.  In  the  meantime  the  left  leg  might  have 
partly  or  entirely  recovered.  A  few  days  later  the  latter  would  be  again 
attacked,  and  from  this  time  on  the  affection,  being  equally  or  unequally 
developed  in  the  two  legs,  would  pursue  its  regular  course.  Sometimes 
paraplegias,  limited  to  the  lower  extremities,  seem  to  have  no  effect  upon 
the  general  system.  Sometimes,  however,  they  prostrate  the  patients 
considerably,  and  are  attended  by  bladder  and  rectal  disturbances,  par- 
ticularly the  former.  Sometimes  the  urine  is  slowly  expelled,  and  some- 
times there  is  complete  retention,  followed  by  incontinence  from  paralysis, 
with  erythema  and  eruptions.  The  rectum  is  more  or  less  paretic,  which 
occasions  constipation,  or,  if  diarrhoea  exist,  involuntary  defecation. 
Again,  the  paralysis  involves  even  the  abdominal  muscles,  and  the  women, 
not  feeling  fcetal  movements,  and  thinking  the  child  dead,  can  only  per- 
suade themselves  that  it  is  alive  by  seeing  the  movements. 

Sensibility  is  differently  affected.  In  some  cases  there  is  slight,  but  in 
others,  profound  anffisthesia.  There  are,  sometimes,  sensations  of  tick- 
Img,  prickling  and  creeping  in  the  paralyzed  limbs.  In  spinal  paraplegias 
there  is,  at  the  seat  of  the  lesion,  constant  pain,  which  may  radiate  either 
toward  the  pubes,  the  thighs,  the  legs  or  the  loins,  or  may  encircle  the 
body,  producing  cramps  and  sensations  of  heat  and  coid.  But  these  sen- 
sations have  nothing  characteristic,  and  motility  may  be  alone  affected. 

These  ^paraplegias  pursue  a  special  course.  Beginning  in  a  gradual 
fashion,  they  rapidly  become  complete,  but  generally  disappear  quite  rap- 
idly. This  is  not  always  true,  and  sometimes  there  is  a  sort  of  transition 
in  the  disease,  which  Jaccoud  has  well  described.  Anaemia  of  the  spinal 
cord  may  lead  to  more  or  less  severe  organic  lesions.  Then  paralysis 
persists,  or,  becoming  general,  it  kills.  In  these  cases  other  symptoms 
appear,  which  prove  that  it  has  clianged. 

These  symptoms  tire  spinal  pains,  spasms,  pains  in  the  paralyzed  limbs. 


DISEASES    OF   PREGNANCY.  155 

which  radiate  to  different  points,  and  sometimes  give  the  patients  no 
peace.  The  muscles  are  wasted,  and  even  complete  atrophy  may  occur. 
Under  the  influence  of  repeated  pregnancies,  these  paraplegias  increase 
in  extent  and  in  gravity. 

Prognosis. — This  varies  with  the  cause.  If  the  paraplegia  is  reflex, 
nnfemic  or  post-homorrhagic,  the  cause  being  transient  and  capable  of  en- 
tirely disappearing  under  proper  treatment,  the  prognosis  is  favorable,  and 
we  may  expect  a  cure,  unless  a  transformation  in  the  type  of  the  disease 
appears.  If  the  paraplegia  be  organic,  the  importance  and  the  gravity  of 
the  lesion  will  decide  the  prognosis.  If  the  cause  is  a  congestion  or  a 
slight  hemorrhage,  we  may  hope  for  a  cure,  although  it  may  be  tardy.  If 
the  case  involves  vertebral  caries,  myelitis  or  medullary  softening,  the 
lesion  will  be  grave  in  proportion  to  the  extent  of  the  disease. 

Diagnosis. — The  chief  point  in  the  diagnosis  is  to  decide  whether  the 
cause  of  the  paraplegia  be  organic,  or  functional  and  reflex,  and  this  is 
not,  generally,  difficult.  If  the  paraplegia  is  of  organic  origin,  it  is  gen- 
erally slowly  progressive,  accompanied  by  radiating  pains  in  the  spine,  by 
formication,  numbness  in  the  legs,  cramps,  spasms,  veritable  contrac- 
tures, analgesia  and  anesthesia,  or  marked  hypergesthesia,  vesical  and 
rectal  disorders,  all  of  which  are  persistent.  The  puerperal  state  is  lost 
sight  of  in  these  cases,  and  the  organic  lesion  is  the  dominating  pathologi- 
cal feature.  When  paraplegia  begins  after  labor,  and  is  not  due  to  trau- 
matism, which  plays  a  special  role,  this  paraplegia  is  only  developed  after 
puerperal  diseases,  and  is  due  to  disease  of  the  lumbar  and  sacral  plexuses, 
dependent  on  inflammatory  changes  in  the  soft  or  the  bony  tissues  of  the 
pelvis.  In  this  case  inflammation  is  propagated  from  these  tissues  to  the 
nervous  plexuses.  The  resulting  paraplegia  follows  in  its  development 
the  evolution  of  the  original  disease,  and,  if  the  patients  recover,  the  par- 
alysis disappears,  either  at  the  same  time  as  the  disease  which  occasioned 
it,  or  at  the  end  of  a  longer  period.  In  such  case,  the  paraplegia,  al- 
though organic,  is  dependent  upon  a  local  condition  which  owes  its  origin 
directly  to  the  puerperal  state.  Our  view  is  thus  quite  different  from 
that  of  Hervieux,  who  considers  these  paraplegias  to  be  the  result  of  a  real 
poisoning  by  what  he  calls  the  puerperal  miasm. 

Keflex  paraplegias  are  never  accompanied  by  spinal  or  lumbar  pains. 
Beginning  insidiously,  i.e.,  with  simple  enfeeblement,  perhaps  of  a  single 
limb,  they  do  not  fail  to  speedily  attack  the  other  limb,  and  to  become 
more  or  less  complete  (sometimes  in  a  few  hours).  The  peculiar  changes 
of  sensibility  noted  among  the  symptoms,  are  particularly  prominent  in 
these  cases.  The  bladder  and  the  rectum  are,  most  frequently,  unaffected 
and  the  paralysis  supervenes,  sometimes  without  known  cause,  and  some- 
times as  the  result  of  an  exposure  to  cold,  of  a  hemorrhage,  or  of  preg- 
nancy alone.  It  occurs  just  as  readily  after  an  easy  as  after  a  difficult 
labor,  and  is  generally  of  short  duration.     If  it  persists,  it  is  because  its 


156  A    TEEATISE    ON    OBSTETRICS. 

type  lias  been  transformed.  Altliougli  these  paraplegias  have  no  effect 
upon  pregnancy,  it  is  not  so  with  labor,  althongh  this  influence  varies  with 
the  cause  and  the  intensity  of  the  paraplegia.  If  the  disease,  for  exam- 
ple, is  slight,  and  limited  to  the  legs,  its  influence  upon  the  course  of  labor 
is  of  no  moment,  but  it  rather  seems  to  hasten  labor  by  diminishing  the 
susceptibility  to  pain.  The  same  does  not  hold  when  the  paraplegia  extends 
to  the  abdominal  muscles.  In  this  case,  labor  is  arrested  at  the  very 
end,  by  failure  of  the  expulsive  power  of  the  abdominal  walls.  (Gamet, 
Depaul,  Brachet.) 

Treatment. — This  varies  with  the  nature  of  the  disease.  In  the  former 
case  revulsives  and  stimulants  to  the  legs,  and  nux  vomica,  meet  the  indi- 
cations. In  the  second  case,  a  tonic  regimen  and  rest  will  usually  suffice 
to  cure  a  disease,  the  natural  tendency  of  which  is  toward  recovery.  If 
the  disease,  even  in  the  second  instance,  proves  a  little  rebellious,  electri- 
city and  baths,  particularly  sulphur  baths,  may  be  useful. 

Traumatic  Paralysis. 

There  is  another  class  of  paralyses,  not  less  interesting,  viz.,  those  in' 
which  the  lesion  affects  only  a  single  limb,  the  upper  or  the  lower,  and  among 
these  paralyses,  traumatic  paralyses  merit  particular  attention.  Inciden- 
tally mentioned  by  Campbell,  Eamsbothain,  Scanzoni,  Komberg,  Jacque- 
mier,  Imbert  Groubeyre,  Bedford,  Burns,  Tarnier,  Siredey,  Jaccoud, 
Axenfeld,  Simon,  Hervieux,  Depaul,  Maringe,  Hosier  and  Froge,  these 
paralyses  were  carefully  studied  by  Bianchi  in  his  thesis  of  1867,  and  we 
were  able  to  collect  eleven  cases.  Since  then,  in  1867,  Lefebvre  has 
cited  four  new  examples,  and  Brivois,  thesis  1880,  two  new  cases,  one 
personally  observed  and  one  borrowed  from  Winckel.  The  total  number 
is  seventeen,  not  great  to  be  sure,  but  important  in  view  of  the  clearness 
and  precision  of  the  facts.  Bianchi,  first  recalling  the  cases  of  paraly- 
sis produced  by  tumors  pressing  against  sacral  nerves  at  their  origins, 
compares  the  foetal  head  to  a  hard,  voluminous  tumor,  which  exerts  ener- 
getic, although  brief  pressure,  causing  paralysis,  generally  temporary,  but 
sometimes  persisting  after  delivery.  Reducing  the  question  to  a  mechani- 
cal problem,  he  states  that  there  exists:  1.  An  active  agent  or  force 
(uterine  contraction).  2.  A  compressing  body  (foetal  head).  3.  A  re- 
sisting surface  (maternal  pelvis).  4.  Organs  exposed  to  compression. 
These  are  the  foetal  head,  the  pelvis,  the  perineal  muscles,  the  hypogas- 
tric vessels,  the  bladder,  the  rectum,  the  nerves,  particularly  the  obtu- 
rator, and  the  sacral  plexus,  particularly  the  great  sciatic  nerve.  Incom- 
pletely protected  against  puerperal  traumatism,  this  nerve  is  necessarily 
compressed  in  all  labors,  but  to  a  variable  extent.  Generally,  the  only 
results  are,  at  the  end  of  labor,  cramps  in  the  calves  and  the  great  toes. 
If  the  nerve  is,  however,  too  long  and  too  forcibly  compressed,  bruised  by 
the  foetal  head  or  by  instruments,  disturbances  which  are  often  serious 


DISEASES    OF    PREGNANCY.  157 

and  lasting,  or  even  true  paralyses,  may  develop  in  the  inferior  extriMni- 
ties,  where  the  terminal  branches  of  the  nerve  are  distributed.  To-flay 
these  traumatic  paralyses  are  universally  admitted,  and  with  Bianchi  Ave 
may  cite  among  their  determining  causes  all  conditions  angmenting  the 
duration  and  the  iiitensity  of  the  compression.  Thus:  the  length  of 
labor,  whether  due  to  weakness  of.  uterine  contractions  or  to  considerable 
resistance,  large  size  of  the  child,  posterior  positions,  pelvic  deformity, 
perineal  resistance,  first  labors,  particularly  the  use  of  forceps,  and  finally 
the  patient's  age.  The  majority  of  cases  occur  in  women  over  thirty  years 
old,  and  especially  in  primiparae.  These  paralyses  are,  nevertheless,  rare, 
and  one  might  assume  a  certain  individual  predisposition,  which  would 
be  favored  in  some  cases  by  the  patient's  age,  the  fact  of  not  having 
borne  children,  and  the  situation  of  the  fcetus. 

Symptoms  and  Diagnosis. — These  paralyses  always  occur  after  labor, 
but,  in  certain  cases,  are  preceded  by  some  phenomena  which  we  might 
consider  precursors  almost  like  the  first  stage  of  a  disease.  These 
are  very  violent  pains,  which  some  patients  experience  in  the  sciatic 
nerve,  during  labor.  Noted  by  all  obstetricians,  these  pains,  which 
occasion  in  many  women  cramps,  formication  and  numbness  of  the 
limbs,  are«  sometimes  so  pronounced  as  to  give  the  labor  a  pathologi- 
cal aspect.  Generally  moderate,  they  assume,  in  some  cases,  an  extreme 
severity  and  impede  labor.  Sometimes  they  specially  affect  the  crural 
nerve  (then  they  are  felt  on  the  anterior  surface  of  the  thighs),  sometimes 
the  obturator  (and  then  they  are  felt  on  the  internal  aspect  of  the  thighs), 
most  frequently  the  great  sciatic  nerve,  occasionally  all  the  nerves  at  once, 
but,  generally,  various  nerves  in  succession,  thus  indicating  the  progress 
of  foetal  engagement.  Thus,  the  pains  due  to  compression  of  the  crural 
and  of  the  obturator  are  felt  before  those  of  the  sciatic  nerve,  and  at  an 
earlier  period  of  labor.  It  is,  in  fact,  upon  this  last  nerve  that  all  the 
compression  exercised  by  the  foetal  head  is  concentrated,  and  this  is  par- 
ticularly true  at  the  end  of  labor.  If  this  compression  has  been  too  long- 
continued  or  too  energetic,  these  pains,  which  generally  disappear  very 
rapidly  after  labor,  may  last  a  longer  or  shorter  time  and  paralyses  may 
succeed  them.  This  particularly  happens  when  this  contraction  has  been 
farther  augmented  by  tractions  upon  the  forceps,  especially  when  these 
tractions  are  wrongly  directed  and  either  too  violent  or  too  long  continued. 
Whether  these  original  pains  exist  or  not,  paraplegia  is  developed  in  all 
the  cases,  very  nearly  at  the  time  for  labor.  Paralyses  appear  after 
twenty-four  or  forty-eight  hours,  or  after  some  days,  at  the  latest.  They 
might  appear  later  without  our  being  able  to  deny  that  they  were  due  to 
traumatism,  (Niemeyer,  Follin,  Velpeau,  Bastion,  Tillaux.) 

Sensation  may  be  abolished,  diminished,  augmented  or  perverted.  This 
abolition  of  sensation  may  be  complete  or  partial,  and  may  consist  of  anal- 
gesia, anaesthesia  or,  most  frequently,  of  the  two  combined.     There  may 


158  A    TEEATISE    ON    OBSTETEIOS. 

even  exist  tliermo-analgesia,  i.e.,  insensibility  of  the  skin  to  different 
temperatures.  Sensibility  may,  on  the  contrary,  be  augmented,  now  con- 
stituting a  true,  traumatic,  diffuse,  disseminated  neuralgia,  without  deter- 
minate limits,  and  often  extremely  severe,  now  corresponding  to  the  course 
of  the  compressed  nerve,  or  localizing  itself  in  certain  points.  Sensibility 
may  be  perverted,  and  then  the  patients  experience  prickling,  tickling 
and  painful  formication,  symptoms  which  may  announce  the  beginning 
of  a  true  hyperaesthesia,  and  may  only  be  transitory,  or  may  lead  to  a  par- 
alysis of  sensation.  Motor  disturbances  may,  in  the  same  way,  vary  from 
a  simple  impairment  of  motility,  awkwardness,  torpor  or  weakness,  up 
to  coQiplete  loss  of  motility.  The  prolonged  absence  of  innervation  re- 
sults, generally  after  a  long  time,  in  a  certain  amount  of  muscular  atrophy. 
The  disturbances  of  secretion  and  vital  heat  are  more  directly  dependent 
upon  the  sympathetic  system.  The  lowering  of  the  temperature  in  the 
diseased  limbs  is  referable  to  local  retardation  of  the  circulation,  due  to  pa- 
ralysis of  the  vaso-motor  filaments  derived  from  the  cerebro-spinal  system, 
which  results  in  vascular  contraction. 

This  description,  borrowed  from  Vul plan, Bastion  and  Tillaux,is  perfectly 
applicable  to  traumatic  paraplegias.  Commencing  moderately,  the  disease 
progressively  reaches  its  maximum,  but  is  almost  always  unilateral,  which 
shows  that  the  compression  has  been  more  strongly  exerted  on  one  of  the 
sacral  plexuses.  The  paralysis  is  generally  incomplete  and  limited,  for, 
since  the  compression  affects  particular  nerves,  the  paralytic  symptoms 
show  themselves  in  the  muscles  which  these  nerves  supply.  Thus,  in  one 
of  Bianchi's  cases,  paralysis  was  especially  well  marked  in  the  muscles 
supplied  by  the  external  popliteal  nerve.  Limited  to  one  limb,  or  to  one 
part  of  a  limb,  the  paraplegia  never  invades  the  rectum  or  the  vagina, 
which  remain  intact  and  preserve  the  integrity  of  their  functions.  Elec  - 
trical  excitability  is  diminished  or  even  abolished. 

The  only  conditions  which  are  liable  to  be  mistaken  for  these  paraple= 
gias,  are  the  pseudo-paraplegias  of  Jaccoud,  and  the  relaxation  of  the  pel- 
vic symphyses,  succeeding  a  difficult  labor,  but  the  differential  diagnosis 
is  easy.  Schmidt  had  a  curious  and  rare  case,  in  which  paraplegia  devel- 
oped in  the  course  of  an  extra-uterine  pregnancy.  These  paraplegias  always 
disappear,  but  sometimes  only  after  months  or  even  years,  and  in  these 
tedious  cases,  we  find  atrophy  of  the  diseased  limbs. 

Treatment. — This  is  preventive,  consisting  in  wise  intervention,  calcu- 
lated to  prevent  compression  of  the  nerves  from  prolonged  contact  with 
the  head,  and  curative,  consisting  in  efforts  to  retain  the  remaining  exci- 
tability of  the  injured  nerves,  and  to  prevent  or  to  arrest  fatty  degenera- 
tion of  the  muscles.  Electricity,  locally  applied,  cutaneous  revulsion,  dry 
or  wet  frictions,  mineral  waters,  baths  and  sulphur  douches  are  indi- 
cated, besides  a  tonic  and  roborant  treatment. 


1 

case. 

5 

2 
8 

cases. 

a 

1 

case. 

2 

cases 

1 

case. 

DISEASES    OF    PREGNANCY.  159 

Partial  Paralyses. 

These  paralyses,  whether  hemiplegic  or  paraplegic,  may  affect  now  an 
upper  and  now  a  lower  extremity,  and  may  either  simultaneously  invade 
the  face  and  one  upper  limb  or  be  limited  to  the  face.  Again,  they  may 
involve  a  limited  muscular  area.  Although  the  causative  influence  of  the 
puerperal  state  is  evident  in  some  cases,  yet  these  paralyses  may  acciden- 
tally develop  in  a  pregnant  woman  without  there  being  an  evident  con- 
nection between  the  palsy  and  pregnancy.  Aside  from  traumatic  paral- 
yses, we  have  collected  the  following  twenty-one  cases: 

Crossed  hemiplegia, 
Paralysis  of  the  upper  extremity, 
loAver  " 

face 
"         "  "    and  arm, 

"         "         shoulders, 
"         '^         extensor  muscles  of  the  neck, 
Hemiplegia  with  contractures. 

One  striking  fact  is  the  comparative  frequency  of  facial  paralysis. 
Next  to  this  comes  paralysis  of  the  arm.  The  hemiplegic  type  largely 
predominates  over  the  paraplegic  in  these  cases  of  partial  paralysis,  and 
these  palsies  are  rarely  isolated,  i.e.,  they  are  complicated  by  impairment 
of  the  senses,  as  of  hearing  and  sight.  Amaurosis,  most  frequently  par- 
tial, may  exist.  Instead  of  always  assuming  a  typical  course,  these  paral- 
yses tend  to  develop  in  one  single  region,  as  in  the  muscles  of  the  face, 
the  shoulders,  or  the  neck.  They  therefore  belong  to  the  class  desig- 
nated as  rheumatic.  On  the  other  hand,  all  authors  have  noted  the 
relation  existing  between  albuminuria  and  rheumatism.  Among  our 
twenty-one  cases,  in  six  albuminuria  existed,  and  in  four  others,  the  pa- 
ralysis coincided  with  a  more  or  less  complete  amaurosis.  These  usual 
impairments  are  among  the  most  frequent  complications  of  albuminuria. 
We,  thus,  believe  that  partial  paralysis  are  due  to  three  chief  causes:  1. 
Albuminuria;  2.   Eheumatism;  3.  Eeflex  action. 

Frequency. — Bare  as  regards  absolute  frequency,  partial  paralyses  are 
frequent  as  compared  with  complete  paralyses.  Thus,  if  we  add  these 
twenty-one  partial  paralyses  to  the  seventeen  traumatic  paralyses,  we  ob- 
tain the  following  figures:  Hemiplegias,  57;  Paraplegias,  25;  Partial  pa- 
ralyses (traumatic  or  otherwise),  38;  total  120. 

After  hemiplegia,  this  is,  therefore,  by  far  the  most  frequent  form. 
Partial  paralyses  may  occur  as  well  during  pregnancy  as  after  delivery, 
after  an  abortion  as  well  as  after  labors  at  term,  and  may  be  recurrent. 
This  happened  once  in  three,  once  in  four,  and  once  in  eight  successive 
pregnancies.  Motility  and  sensibility  are  alike  affected,  and  we  may 
have  all  the  varieties  noted  above.  Sometimes  the  palsies  begin  sud- 
denly, and,  sometimes,  are  preceded  by  discomfort,  head-ache  and  visual 


160  A    TREATISE    ON    OBSTETEICS. 

troubles.  Occasionally  the  paralysis  lias  been  preceded  by  weakness^ 
numbness  and  pains  in  the  limbs,  and  has  slowly  and  progressively  grown 
more  marked  until  sensation  and  motion  have  been  entirely  lost.  Occasion- 
ally, however,  it  has  begun  suddenly  without  premonition s.  It  may  present 
the  same  varieties  mentioned  under  the  head  of  complete  paralyses,  whi-ch 
enable  us  to  make  the  diagnosis,  to  which  we  need  not  revert  at  present. 
Let  us  only  mention  hysterical  paralyses,  which  are  distinguished  by  the 
concomitance  of  other  hysterical  phenomena  which  render  the  diagnosis 
clear. 

Paralyses  of  the  Senses. 

These  paralyses  are  almost  always  dependent,  it  is  true,  upon  albumin- 
uria, but  they  may,  in  rare  instances,  be  attributed  to  hysteria,  ansemia 
or  dyscrasise.  The  fact  of  their  persistence  shows  that  albuminuria  is 
not  their  only  cause.  Rarely  isolated,  they  are  often  accompanied  by 
paralyses  of  several  other  special  senses,  particularly  of  hearing  and  sight. 
Again,  they  may  coexist  with  paralyses  of  the  face  or  of  the  limbs. 
Disturbances  of  vision  are  by  far  the  most  frequent.  These  troubles  may 
present  various  degrees.  Sometimes  the  sight  is,  at  first,  clear  and  only 
grows  dim  after  use.  Sometimes  there  is  complete  loss  of  vision.  Some 
patients  become  color-blind,  others  become  myopic,  and  others  present, 
at  the  same  time,  exophthalmos,  strabismus  and  prolapse  of  the  lids. 
The  cornea  and  the  sclerotic  are  healthy,  the  pupils  are  not  very  contrac- 
tile and  are  often  dilated.  The  retina  and  the  choroid  may  present  nu- 
merous and  varied  alterations,  but  often  are  in  a  normal  state.  In  cer- 
tain cases,  the  amaurosis  coexists  with  lesions  of  motility  and  of  sensi- 
bility in  the  limbs.  Besides  these  visual  troubles,  referable  to  albumin- 
uria, we  must  mention  those  following  large  puerperal  hemorrhages, 
those  due  to  toxic  doses  of  lead  or  quinine,  (we  have  seen  one  such  case 
which  lasted  four  months)  and  those  referable  to  syphilis  or  to  other  ca- 
chexige.  We,  finally,  see  these  impairments  of  sight  accompanying  the  dis- 
eases of  the  post-'parUim  state,  whether  inflammatory  or  not.  Lastly,  in 
Lebreton's,  BouUey's  and  Landry's  cases  of  hysterical  paralyses,  tliere 
were  marked  visual  difficulties.  We  believe  albuminuria  is  the  chief  path- 
ological agent.  The  same  applies  to  deafness,  although  it  may  be  more 
generally  connected  with  general  depression  of  the  system.  Although, 
indeed,  deafness  sometimes  depends  upon  albuminuria,  it  is  oftener  due 
to  the  adynamia  attending  puerperal  septicemia,  and,  in  one  of  our  own 
cases,  we  found  albuminuria  to  be  wanting.  The  observations  of  Oapu- 
ron,  of  Liegey  and  of  Prestat  regarding  paralyses  of  smell,  of  taste  and  of 
the  voice,  seem  to  us  at  least  doubtful. 

Must  puerperal  mania,  which  Imbert  Gourbeyre  considers  to  be  a 
paralysis  of  the  intellect,  be  classed  with  these  ?  We  do  not  think  so,  and 
we  hold  that  the  following  restime  from  our  monograph  states  the  essen- 
tial points  regarding  puerperal  paralysis: 


DISEASES    OF    PREGISTANCY.  161 

1.  Puerperal  Avomen  are  suljjected  to  the  same  causes  of  paralysis  as 
non-puerperal  subjects. 

2.  The  puerperal  state,  nevertheless,  constitutes  with  them  a  predis- 
posing and,  in  certain  cases,  even  an  exciting  cause. 

3.  These  palsies  may  occur  at  any  period  of  the  puerperal  state,  whether 
during  pregnancy,  labor  or  the  puerperium,  but  are  much  more  frequent 
in  the  first  and  the  last  named  periods. 

4.  There   are  three  forms  of  these  paralyses:  hemiplegia,  paraplegia 
and  paralysis  of  the  special  senses.     Each  of  the  first  two  may  be  accom- 
panied by  the  third,  particularly  the  first. 

5.  These  paralyses  may  be  complete  or  incomplete,  partial  or  general, 
i.e.,  they  may  affect  one  side  (hemiplegia)  or  only  the  lower  limbs  (para- 
plegia), and  involve  either  one  member  or  both  simultaneously. 

6.  These  palsies  may  exist  in  clearly  distinct  forms  by  themselves,  or 
may  be  accompanied  by  paralysis  of  the  special  senses,  as  of  sight  and  hear- 
ing, which  latter  may,  of  themselves,  constitute  the  sum  total  of  paraly- 
tic symptoms. 

7.  The  hemiplegias  and  the  disorders  of  special  senses  are  often  ac- 
companied by  facial  paralyses,  which  are  rarely  isolated,  but  generally 
combined  Avith  either  partial  paralysis  of  the  limbs  or  Avith  paralysis  of 
the  special  senses. 

8.  These  palsies,  of  Avhatever  form,  affect  both  motility  and  sensibility, 
and  present  every  possible  variety  from  simple  paresis  to  complete  paralysis. 

9.  These  paralyses  may  be  separated  into  two  chief  groups:  A.  Paraly- 
ses from  organic  lesions;  B.  Paralyses  from  reflex  action.  The  paralyses 
from  organic  lesions  may  be  subdivided  into  two  classes:  a.  Primitive 
organic  lesions  ;  congestions,  hemorrhages,  meningitis,  and  lesions  of  the 
cranial  bones  or  of  the  vertebrge;  h.  Secondary  or  consecutive  organic 
lesions;  congestion,  hemorrhage,  meningitis,  heart  affections,  cerebral 
thromboses,  albuminuria,  uterine  affections  and  compressions  of  the 
nerves.     Keflex  paralyses  are  due  to  peripheral  irritation. 

10.  The  puerperal  state  not  only  does  not  protect  women  against  the 
causes  of  paralysis  other  than  those  which  we  have  mentioned,  as  rheu- 
matism, chloro-ansemia  and  hysteria,  but  seems  to  predispose  the  patients 
to  palsy  from  these  causes,  by  producing  abnormal  hasmic  conditions. 

11.  Puerperal  paralyses  are  generally  slight  and  transient,  but  this  is 
particularly  true  of  reflex  paralyses,  for  hemiplegias,  paraplegias  and  pa- 
ralyses of  the  special  senses  may  be  of  indefinite  duration. 

12.  Organic  paralyses  borroAv  their  character,  as  regards  gravity,  from 
the  nature  of  the  causative  conditions,  being  either  temporary,  perma- 
nent or  even  fatal,  as  the  case  may  be. 

13.  The  lesions  most  frequently  reported  are:  cerebral  hemorrhage, 
cerebral  or  spinal  meningitis,  Avhether  alone  or  accompanied,  as  they  fre- 
quently are,  by  renal  degenerative  changes. 

Vol.  II.— 11. 


162  A    TREATISE    OIS"    OBSTETRICS. 

14.  The  frequent  coexistence  of  tliese  renal  lesions,  and  of  cerebral  or 
medullary  lesions,  shows  hoAV  important  albuminuria  is  in  the  pathogeny 
of  puerperal  palsies. 

15.  It  is  possible,  within  certain  limits,  to  establish  a  precise  diagnosis 
of  the  cause  of  these  puerperal  paralyses,  and  this  cause  once  being 
known,  to  establish  a  prognosis  which  will  be  surer  in  proportion  as  the 
cause  of  the  ^^aralysis  is  better  known. 

16.  The  treatment  must  depend  on  the  causes,  some  of  which  are  per- 
manent, the  others  being  transitory  and  temporary. 

Intellectual  Disturbances. 

These  are,  as  Marce  says,  of  two  kinds.  One  consists  in  simple  moral 
tendencies,  which  do  not  deprive  the  patient  of  free-will,  but  impart  a 
peculiar  character  to  her  manner  and  her  physiognomy.  The  other  is  a 
state  of  mental  alienation,  variable  in  type  but  well-marked.  In  the  first 
instance,  the  disorders  are  very  different,  as  caprices,  whimsicalities, 
changes  of  disposition,  variable  moods,  new  tastes,  unreasonable  antipa- 
thies— disorders,  in  short,  affecting  either  the  whole  of  the  mental  facul- 
ties or  only  one  of  them,  (understanding,  sensibility,  will.  Boudrie.) 
Thus,  one  sees  women  who,  having  been  remarkable  for  the  sweetness 
and  amenity  of  their  character,  become  sad,  morose,  sour,  violent  even, 
and  unable  to  endure  the  presence  of  persons  hitherto  dear  to  them. 
Others,  inclined  to  be  naturally  sad,  melancholy,  grave  or  serious,  de- 
velop an  activity  and  a  gayety  surprising  to  their  friends.  Still  others, 
joarticularly  primiparje,  await  their  confinement  with  terror,  and  are  per- 
suaded that  they  will  not  survive,  the  trial  which  is  before  them.  Hence 
they  grow  melancholy,  and  conceive  fears  regarding  the  proper  develop- 
ment of  their  children.  Marce  quotes,  from  Vandermonde,  the  history 
of  a  woman  who  had  a  horror  of  water  during  the  first  foTir  months  of 
each  of  her  eleven  pregnancies.  In  certain  cases,  the  nervous  distur- 
bance eventuates  in  true  mental  alienation,  or  puerperal  mania.  On  this 
subject,  however,  authors  do  not  agree.  Insanity  may,  indeed,  manifest 
itself,  not  only  in  pregnant  women,  but  during  labor  in  the  puerperium, 
and  even  in  lactation.  So,  while  some  authors  describe  the  mental 
alienation  occurring  at  these  different  periods  under  the  generic  term, 
puerperal  mania,  others  reserve  this  name  exclusively  for  those  cases  of 
insanity  developed  during  the  puerperium.  Others  add  the  insanity  of 
lactation,  making  the  mania  of  pregnant  women  a  variety  by  itsalf,  viz., 
sympathetic  insanity.  Aside  from  the  emotional  character  peculiar  to 
pregnant  women,  there  is  an  undeniable  sympathy  between  uterine  dis- 
turbances and  intellectual  disorders. 

These  conditions  have  been  found  by  Lisfranc,  Azam  and  others  when 
pregnancy  did  not  exist.  Much  more  should  they  obtain  when  there  ex- 
ists a  long-continued  irritation,  such  as  is  produced  by  the  presence  of 


DISEASES    OF   PREGNAISTCY.  163 

the  foetus  in  nfcero.  But  this  sympathy,  existing  in  pregnancy,  is  not  un- 
derstood in  tlie  same  way  by  all  authors,  and  is  even  rejected  by  some. 
Thus,  while  Falret,  Georget  and  Scanzoni  deny  it,  Le  Grand  du  SauUe, 
Tarnier,  Dagonet  and  Rocher  positively  admit  it.  Others,  like  Marce, 
Brierre  de  Boismont,  Baillarger  and  Morel  admit  it  with  certain  reserva- 
tions, and  although  they  admit  the  sympathy,  consider  it  to  be  imperfect. 
Marco  expresses  himself  thus:  "  If  we  consider  it  proper  to  exclude  from 
the  class  of  sympathetic  manias,  (taking  this  term  in  its  strictest  accept- 
ation), those  which  are  developed  after  labor,  during  lactation  or  after 
weaning,  we  reserve  the  term  for  those  causes  of  transient  insanity  occur- 
ring during  labor,  and  disappearing  so  soon  as  confinement  is  terminated; 
for  those  mental  affections  which,  beginning  at  conception  or  during  the 
early  days  of  pregnancy,  cease  after  the  termination  of  the  puerperal 
state;  and,  finally,  for  those  rare  cases  in  which  a  delirium  of  a  few  hours' 
duration  accompanies  the  milk  fever  and  disappears  with  it.'' 

This  sympathy  cannot  be  absolutely  denied,  and  the  material  proof  of 
its  existence  has  been  furnished  by  Voisin,  who  discovered,  by  the  aid  of 
the  microscope,  a  large  number  of  embryoplastic  nuclei,  particularly  in 
the  semilunar  ganglion,  and  at  a  more  advanced  period,  fusiform  bodies 
and  distortion  of  the  nerve-cells,  which,  filled  with  fatty  and  pigmentary 
granules,  are  mingled  with  healthy  cells  or  with  other  atrophied  cells. 

Nor  do  authors  agree  as  to  the  significance  of  the  term  puerperal  state, 
or  as  to  the  limits  whiph  should  be  assigned  to  the  term  puerperal  mania. 
While  Griesinger  reserves  this  title  for  intellectual  derangements  mani- 
fested during  and  after  labor,  Monneret  and  Marce  consider  all  derange- 
ments occurring  from  conception  to  weaning  as  puerperal  insanity.  We 
think  that  the  puerperal  state  includes,  at  once,  both  narrower  and  broader 
limits,  and  wliile  admitting  Eaymond's  classification  of  minor  puerperal 
state,  (pregnancy)  and  major  puerperal  state  {post-jjartum  state)  we  be- 
lieve that  the  true  puerperal  state  begins  with  pregnancy  and  terminates 
with  the  2)0st-piarttLm  state.  It  is  unnecessary  to  include  lactation,  but 
since  some  authors  compare  the  mania  of  women  just  delivered  with  those 
of  nursing  women,  we  think  that  the  insanity  of  pregnant  women  should 
be  included  in  the  same  category,  and  that  the  phenomena  of  mental 
alienation  occurring  in  pregnancy,  labor,  the  puerperium,  and  lactation 
are  all  intimately  connected.  Sympathy,  if  one  will,  but  the  puerperal 
state  and  the  exhaustion  due  to  lactation,  impress  peculiar  characters 
upon  this  alienation.  We  might,  perhaps,  make  three  special  chapters  of 
the  subject,  as  Marce  does,  but  to  our  mind,  Eocher  went  too  far  when 
he  said:  "  It  is  well  enough  to  treat  of  the  mania  of  women  who  are  preg- 
nant, but  it  must  not  be  called  puerperal  mania."  True  puerperal  mania, 
we  admit,  will  manifest  itself  three  or  four  weeks  after  labor,  but  it  seems 
impossible  to  us  to  separate  it  entirely  from  the  insanity  of  pregnant  or 
of  nursing  women.   We  therefore  include  these  forms  in  our  study. 


164 


A    TEEATISE    ON    OBSTETEICS. 


Frequeiicy. — It  is  difficult  to  collect  trustworthy  statistics  regarding 
puerperal  mania,  for  it  often  does  not  appear  until  after  the  patients  have 
left  the  hospital.  The  following  figures  have,  therefore,  only  a  relative 
value.      Thus: 


Women  Delivered. 


Eeid,     among  3,500  found 
Gream,         "    3,000      " 
Behier,         "   1,000 

Leidesdorff,''       200 


j  during  pregnancy,  6  \ 


puerperal  state,  14  f 


9  cases. 
11     " 
1  case. 

20  cases. 


Among  the  fourteen  cases  occurring  in  the  puerperal  state,  Leidesdorff 
saw  eight  develop  from  the  sixth  to  the  tenth  day,  five  from  the  third  to 
the  eighth  week,  one  at  the  twelfth  week. 

On  the  other  hand,  the  proportion  of  cases  of  puerperal  mania  compared 
with  the  total  number  of  the  insane,  furnishes  much  more  positive  data. 
Thus: 

Puerperal  origin. 
Esquirol,       .         .         .      among  1,119  insane,  found    92  cases. 


"         (private 
Eeid,    . 

practi 

ce) 

144     " 
899     " 

21 
'      111 

Haslain, 

1,644     " 

84 

Hanwell, 

703     " 

79 

Macdonald,  . 

691     " 

49 

Parchappe,  . 
Zeller, 

596     " 
97     " 

33 
11 

Webster, 

282     " 

17 

Kirkbride,    . 

2,752     " 

'      116 

Marce, 

a 

242     " 

9 

Hence, 

9,179     "  there 

are  622 

That  is,  about  1  out  of  every  14.7. 

The  following  table  shows  the  relative  frequency  of  the  cases  in  preg- 
nancy, in  the  puerperium,  and  in  lactation. 


Number 
of  cases. 

Pregnancy. 

Puerperium,  '. 

l,actat 

Palmer, 

19 

1 

6 

12 

Esquirol, 

92 

0 

54 

38 

Hanwell, 

43 

4 

26 

13 

Macdonald,    . 

66 

4 

44 

18 

Marco,  . 

310 

27 

180 

103 

Tuke,    . 

155 

28 

73 

54 

Leidesdorff,   . 

20 

6 

14 

0 

Insanity  during  pregnancy  is,  therefore,  much  the  most  rare. 
Causes. — In  the  first  place:  1.   Heredity,  i.e.,  a  predisposition  which 
Griesinger  calls  a  psychopathic  diathesis,  transmitted  by  ancestors  affected 


DISEASES   OF    PREGNANCY. 


165 


by  insanity,  diverse  neuroses,  hysteria,  epilepsy,  etc.,  in  brief,  by  phreno- 
and  nenro-pathies.     Thus: 

tary  ones. 


Esquirol, 

amor 

ig  28 

cases, 

found  10  heredi 

He] ft,  of  Berlin, 

131 

"      51 

Weill,    . 

30 

'•'      14 

Marce,  . 

56 

u      24 

Eobert  Lloyd, 

63 

"      13 

Reid,      . 

111 

"      45 

Webster, 

131 

CC            5J 

Macdonald,    . 

GCj 

''      26 

2.  Altei^ed  blood  states — tJie  Dyscrasice. — a.  Anemia,  which  may  ante- 
date pregnancy  or  be  its  result.  Its  causes  may  be  repeated  pregnancies, 
hemorrhages  either  daring  pregnancy  or  during  and  after  parturition; 
exhaustion  from  lactation,  and,  in  the  poorer  classes,  bad  or  inadequate 
food,  fatiguing  work,  unhealthful  dwellings,  lack  of  sleep — in  brief,  all  the 
causes  of  debility,  h.  Hypersemia;  active  or  passive  congestions;  Laserre's 
serous  congestions. 

3.  Rejjeated  Pregnancies. — Thus: 

Patients.     Primiparge.     Multiparas. 
Marce,      ....     among    57  14  43 

Tuke,       ....''       101  17  84 

Eobt.  Llovd,    ..."         63  10  53 

Macdonald,      .       '  .         .         ''         66  29  37 


28^ 


ro 


517 


Thus,  among  287  patients,  70  were  primiparse  and  217  multiparge. 

4.  Age. — Marce,  among  55  cases,  found:  At  18  years,  1  case;  from  30 
to  35  years,  13  cases;  from  20  to  25  years,  13  cases;  from  35  to  43  years, 

5  cases;  from  25  to  30  years,  17  cases;  at  40  years  and  upward,  6  cases. 
Reid,  among  1771  cases,  found:  Under  20  years,  69  cases;  from  40  to 

45  years,  54  cases;  from  20  to  30  years,  1,100  cases;  from  45  to  50  years, 

6  cases;  from  30  to  40  years,  542  cases. 
Tuke  found,  among  155  cases: 

Pregnant  women,       .         .     28 

Women  already  delivered,  .     73 

Nursing  women,         .         .     54 

5.  Consanguinity. — This  cause  has  no  effect,  according  to  Brierre  de 
Boismont,  Lagneau,  Peter  and  others,  unless  the  related  parents  are  them- 
selves insane  or  suffering  from  the  psychopathic  diathesis.  .  In  this  case, 
they  transmit  to  their  progeny  a  double  predisposition. 

6.  Sex. — A  certain  influence  is  attributed  to  the  generally  fuller  devel- 
opment of  boys,  but  this  is  not  proven. 


From  15  to  29  vears,  . 

17 

"     31  "  44"  "       . 

11 

From  20  to  30  years,  . 

44 

''     31  "  43     "       . 

29 

From  19  to  30  years,  . 

39 

"     31  "  42     '' 

24 

166  A  tkeatisj:  on  obstetrics. 

7.  Moral  Causes. — These  are  beyond  question,  and  act  both  as  predis- 
posing and  as  exciting  causes,  particularly  the  latter.  Eocher,  although  he 
attributes  to  them  an  important  part,  yet  makes  this  reservation,  that  one 
ought  always  to  assign  to  the  temperament  its  share  of  the  responsibility. 
The  emotional  nature  of  the  pregnant  women  justifies  the  fear  that  her 
extreme  nervous  excitability  may,  under  the  existing  special  physiological 
circumstances,  be  the  avenue  for  the  entrance  of  intellectual  disorders. 
He,  however,  willingly  admits  that  this  nervous  state  is  not  the  indispen- 
sable auxiliary  of  moral  shocks,  and  that  a  sudden,  violent  emotion,  may 
immediately  precipitate  an  attack  of  mania. 

Berard,  Esquirol  and  others,  have  noticed  that  moral  causes  exercise 
their  pernicious  influence,  particularly  among  the  higher  classes  of  society. 
The  lower  classes  are  more  affected  by  physical  causes.  Nevertheless,  the 
part  played  by  moral  causes  in  the  evolution  of  puerperal  insanity,  is  per- 
ceptibly greater  than  that  of  the  physical  causes.  Esquirol  estimated  the 
relation  as  4  to  1;  Weil  as  12  to  6.     Marce  alone  reverses  the  proportions. 

8.  Physical  Causes. — Writers  have  mentioned  dystocia,  obstacles  to 
delivery  and  obstetrical  operations.  Marce,  however,  remarks  that  insan- 
ity shows  itself  as  frequently  after  prompt  and  easy  labors  as  after  long 
and  painful  ones. 

Return  of  Menstruation. — The  mania  may  appear  before  or  during  the 
first  menstruation,  or  hemorrhages.  There  is  another  cause,  the  influ- 
ence of  which  cannot  be  disputed,  in  view  of  the  frequency  with  which 
puerperal  mania  succeeds  it,  viz.,  eclampsia.  All  authors  agree  in  con- 
sidering puerperal  mania  as  a  relatively  frequent  termination  of  eclampsia. 
Chloroform  has  been  accused,  but  authors  do  not  agree  about  it.  Webster 
admits  this  cause,  basing  his  views  upon  five  of  his  cases,  while  Simpson 
opposes  to  these  cases  three  of  his  own,  where  the  women,  being  predis- 
posed by  heredity,  had  most  happy  deliveries  after  the  use  of  chloroform, 
but  were  attacked  by  mania  in  their  next  confinements  when  chloroform 
was  pnt  aside.  Waters  not  only  does  not  regard  chloroform  as  a  cause  of 
puerperal  insanity,  but  proposes  it  as  the  best  means  of  preventing  and 
curing  mania.  Finally,  we  should  mention  prolonged  lactation,  forced 
weaning  and  abscesses  of  the  breast,  and  will  recall,  as  matters  of  histori- 
cal interest,  the  old  theories  of  the  suppression  of  lochia  and  of  milk 
metastases,  besides  Esquirol's  view  regarding  the  etiological  effects  of  cold, 
which,  in  ten  of  his  cases,  is  said  to  have  been  the  cause  of  insanity. 

2.    MaISTIA  of  PREGN"A]SrT  WoME]sr. 

Melancholia  is  the  most  frequent  of  all  the  forms  of  insanity  in  pregnant 
women.  Mania  is  the  next  most  frequent.  The  insanity  may  begin  at 
any  time,  from  the  commencement  of  conception,  which  is  rare,  up  to 
the  end  of  the  ninth  month,  i.e.,  up  to  some  weeks  before  delivery.  The 
number  of  cases  increases  after  the  eighth  month,  attains  its  maximum 


DISEASES   OF    PESSGNANCY.  167 

frequency  at  about  the  seventh  or  eighth  month  and  then  diminishes. 
Sometimes  the  disease  bursts  out  suddenly,,  which  is  rare.  As  a  rule, 
it  appears  slowly  and  increases  gradually.  The  intellectual  disturbances 
which  attend  pregnancy  grow  more  and  more  marked,  and  disorders  of 
volition  and  of  observation  are  soon  added.  The  disposition  is  altered, 
sleep  first  becomes  agitated  and  then  is  replaced  by  insomnia,  and  the 
patients  complain  of  head-ache  and  digestive  troubles.  Then  true  mental 
alienation,  generally  of  the  melancholic  type,  makes  its  appearance.  In 
other  cases,  the  maniacal  form  predominates,  and  then  generally  suddenly 
explodes,  either  without  prodromata  or  after  attacks  of  eclampsia.  Some- 
times there  is  simply  weakness,  languor  and  inertia,  a  sort  of  stupor  with 
suicidal  ideas,  and,  sometimes,  there  is  excitement  with  ideas  of  murder 
and  hallucinations.  Again,  there  may  be,  in  the  maniacal  form,  excite- 
ment, insomnia,  irritability  and  paroxysms  of  furious  mania.  There  is, 
sometimes,  albuminuria,  but  this  is  sometimes  absent.  Garcia  Rijo  has 
reported  inequality  of  the  pupils. 

Prognosis. — Generally,  the  i^insanity  disappears  after  labor,  but  it  is 
not  always  so.  Among  the  nineteen  cases  of  Marce,  the  disease  proved 
incurable  in  nine,  or  only  disappeared  long  after  labor;  in  seven  cases, 
labor  was  the  point  of  departure  for  the  cure.  In  two  of  our  own  cases 
the  insanity  ceased  abruptly,  once  with  the  expulsion  of  the  child,  even 
before  the  expulsion  of  the  placenta.  In  the  second  case  insanity  ap- 
peared at  the  sixth  month,  disappeared  at  the  ninth,  reappeared  five 
weeks  after  labor,  lasted  six  months,  and  then  disappeared  but  not  com- 
pletely. In  one  case,  Marce  saw  the  insanity  aggravated  by  labor,  and 
death  rapidly  supervene  during  the  confinement. 

Among  Leidesdorff's  six  cases  were  four  women  who  had  presented 
psychical  troubles  before  marriage.  The  insanity  became  serious  during 
pregnancy,  and  melancholia  followed  labor.  Of  the  two  others,  in  whom 
insanity  began  dnring  pregnancy,  one  saw  her  mania  augmented  by  labor, 
and  one  recovered  immediately  after  delivery.  Esquirol  saw  one  case  in 
which  insanity  reappeared  in  five  consecutive  pregnancies,  disappearing 
each  time  after  confinement. 

Among  the  twenty  cases  of  Leidesdorff,  during  pregnancy  and  the 
puerperal  state,  there  were  ten  cures  and  one  fatal  case.  In  eight  cases 
insanity  remained.  Esquirol  saw  only  six  deaths  in  ninety-two  cases; 
Webster  five  in  one  hundred  and  eleven  cases.  After  labor  the  insanity 
seems  much  more  serious  and  the  maniacal  form  has  by  far  the  worst  prog- 
nosis. Thus,  there  were,  among  fifty-seven  patients  seen  by  Burrows: 
Cures  (28  in  the  first  six  months),  35;  deaths,  10;  incurables,!;  suicide,!. 

Among  eight  cases  of  insanity  developed  during  labor  or  after  deliver}^, 
seven  of  which  had  hereditary  antecedents.  Burrows  saw:  Melancholia 
and  homicidal  monomania,  !  case,  cure  in  9  months;  mania  and  melan- 
cholia, !  case,  cure  in  1-4  months;  melancholia,  !  case,  cure  in  !  year;  mel- 


168  A   TREATISE    OjST    OBSTETRICS. 

ancliolia,  1  case,  cure  in  6  montlis;  melancbolia,  1  case  ended  in  incurable 
dementia;  abortion  at  four  months,  1  case,  suicide;  abortion  at  three 
months  with  six  attacks  of  mania  before  marriage,  1  case;  incurable  in- 
sanity developed  at  four  months.  Among  Leidesdorff's  twelve  cases  dur- 
ing the  puerperal  state,  from  twenty  to  twenty-nine  years,  there  were: 
Melancholia,  8  cases;  mania,  3  cases;  dementia,  1  case.  There  were 
eight  cures:  five  in  four  months;  two  in  six  months  and  one  in  a  year. 

It,  therefore,  appears  that  sometimes  the  cure  follows  closely  upon 
labor,  but  that  it  sometimes  occurs  only  after  a  certain  number  of  months. 
In  general,  there  is  notable  improvement  after  the  first  weeks  following 
confinement.  It  is  rare  to  see  insanity  develop  and  disappear  during 
pregnancy.  Sometimes  the  patient  is  improved  considerably,  and  a 
happy  termination  is  expected,  when  a  sudden  relapse  destroys  this  hope, 
and  only  confinement  can  change  the  aspect  of  the  disease.  In  the  ma- 
jority of  cases,  labor  has  no  influence  or  a  very  doubtful  one.  Finally, 
acute  mania  may  develop,  and  death  result  more  or  less  speedily. 

Treatment.  — This  should  be,  above  all,  hygienic,  and,  with  Marce,  we 
absolutely  reject  the  induction  of  premature  labor  and  of  abortion. 
What  is,  then,  the  influence  of  insanity  upon  pregnancy  and  of  pregnancy 
upon  insanity  ?  The  effect  of  insanity  upon  pregnancy  is  nil,  and  women 
affected  by  puerperal  insanity  carry  their  children  to  fall  term.  Burrows, 
however,  has  cited  the  two  cases  of  abortion  alluded  to  before.  Does 
the  same  statement  hold  true  regarding  the  influence  of  pregnancy  upon 
insanity  ?  What  are  the  consequences  of  pregnancy  occurring  in  an  in- 
sane person  ?  It  is  a  popular  notion  that  pregnancy  cures  insanity,  but 
this  view  has  no  actual  basis  in  fact,  and  if,  in  exceptional  cases,  pregnancy 
and  labor  happily  modify  insanity,  there  are  innumerable  cases  in  which 
there  is  no  such  modification.  One  cannot  too  strongly  condemn  the 
practice  of  some  physicians  in  recommending  pregnancy  for  insane  women, 
not  amenable  to  the  ordinary  therapeutic  agents.  In  some  rare  cases, 
however,  pregnancy  has  had  the  singular  effect  of  checking  the  advance 
of  mental  alienation,  but,  labor  being  once  completed  and  the  patient  re- 
stored to  her  ordinary  condition  of  health,  the  nervous  tronbles  reappear 
with  equal  intensity.  There  are  still  other  cases  in  which  parturition  has 
had  a  plainly  beneficent  influence  in  aiding  the  cure  of  a  paroxysm  of 
insanity.  Marce  has  collected  five  such  cases.  G-enerally,  the  course  of 
pregnancy  is  not  interrupted  by  distressing  incidents.  A  remarkable  fea- 
ture, observed  in  our  two  patients,  was  the  slight  intensity  of  the  labor 
pains.  In  certain  cases,  several  of  which  Marce  mentions,  the  patients 
are  not  aware  of  their  delivery.  There  seems  to  be  a  difference  between 
the  children  whose  mothers  were  insane  at  the  time  of  conception,  and 
those  whose  mothers  became  insane  during  pregnancy.  In  the  former 
case,  the  children  are  born  healthy,  but  in  the  second  case,  they  are  often 
still-born  or  die  soon  after  birth.     In  our  two  cases  the  children  were  born 


DISEASES    UF   PKEGNANCY.  169 

in  perfect  health.  In  these  cases,  the  children  are  certainly  subjected 
to  that  hereditary  influence  which  plays  so  important  a  role  in  the  etiology 
of  mental  diseases,  but  it  is  not  true  that  their  intellectual  condition  need, 
necessarily,  be  affected  by  that  of  their  parent. 

Even  in  1826  Bouchet  noted,  in  twenty-two  cases,  this  absence  of  ame- 
lioration in  the  mental  state  from  pregnancy  and  labor,  while  See  and 
Montgomery  reported  a  temporary  aggravation  during  cervical  dilatation. 

Temporary  Insanity  at  the  Time  of  Delivery. 

Sometimes  labor  does  not  limit  itself  to  the  production  of  the  agitation, 
anxiety  and  irritability  which  all  accoucheurs  have  observed,  but  attacks 
the  intelligence  or  even  leads  to  the  development  of  maniacal  delirium. 
These  cases,  which  are  rare,  may  be  classed  in  two  categories,  as  Marce 
has  done.  "  In  one  variety,  the  actions  and  words  are  of  constant  inco- 
herence, while  in  the  other,  the  delirious  actions  instigated  by  the  severe 
pains  of  labor  are  logically  related  to  their  point  of  origin.  Thus,  some 
women,  in  real  frenzy,  seek  to  inflict  violence  upon  themselves  or  the 
child,  to  abridge  their  sufferings.  In  many  cases,  the  intellectual  trouble 
assumes  the  characters  of  acute  mania.  There  is  complete  incoherence; 
patients  have  no  appreciation  of  their  condition,  and  nothing  in  the  symp- 
toms betrays  the  physical  and  moral  causes  which  occasioned  the  deli- 
rium.'^  It  is,  therefore,  a  sympathetic  phenomenon,  encountered  most 
frequently  in  diflicult  labors,  but  also,  sometimes,  in  natural  ones,  when 
it  coincides  with  the  expulsion  either  of  the  foetus  or  of  the  placenta.  In 
sjjite  of  its  apparent  gravity,  this  delirium  has  no  serious  consequences. 
It  ceases  spontaneously  when  labor  ends,  and  in  the  cases  where  it  is  pro- 
longed after  delivery,  it  rarely  lasts  more  than  a  few  days  and  hardly  ever 
ends  in  mania.  The  most  rational  treatment  consists  in  terminating  labor 
as  rapidly  as  possible,  and  in  then  adopting  expectant  measures. 

Insanity  of  Women  just  delivered  and  of  nursing  Women. 

Tloe  types  of  insanity  observed  in  these  cases  are:  Mania,  melancholia, 
lypomania,  partial  involvement  of  the  intellect,  hallucinations,  intellec- 
tual or  instinctive  monomania,  alternate  insanity  or  duplex  insanity,  and 
simple  dementia.  These  forms  are  far  from  being  equally  frequent. 
Among  forty-four  cases  Marce  found  twenty-nme  of  mania,  ten  of  melan- 
cholia, five  of  partial  insanity,  and  only  two  cases  of  temporary  intellec- 
tual enfeeblement.  In  nursing  women  melancholia  is,  at  least,  as  com- 
mon as  mania.  The  number  of  monomanias  is  hardly  equal  to  one-fifth 
of  the  cases  of  mania. 

Among  forty-four  cases,  the  insanity  Appeared  within  the  first  ten  days 
in  thirty-three  cases.  Sometimes  the  delirium  appeared  on  the  first  or 
second  day,  but  most  often  did  not  develop  or  attain  its  maximum  until 
the  fourth  or  fifth  day.     The  inception  of  insanity  on  the  tenth  day  is 


170  A    TEEATISE    ON"    OBSTETRICS. 

quite  rare.     In  eleven  cases  insanity  developed  at  about  the  sixth  week, 
i.e.,  at  the  return  of  the  menses.     (Marce.) 

I.   Mania. 

The  attack  is  sometimes  sudden,  but  generally  gradual,  and  accom- 
panied by  precursory  symptoms,  lasting  from  some  hours  to  several  days. 
The  women  are  sad,  morose,  but  more  often  excited.  Their  manners 
and  behavior  become  modified,  the  senses  grow  more  acute,  the  slightest 
noise  or  too  bright  a  light  causing  suffering;  the  agitation  is  aggravated 
day  by  day,  and  violent  mania  developes.  Insomnia  becomes  complete, 
the  tongue  is  coated,  the  mouth  slimy,  the  head  more  painful  and  the 
pulse,  accelerated  during  the  moments  of  agitation,  beats  more  quietly  so 
soon  as  the  woman  groAvs  calmer.  Hallucinations  of  sight  and  hearing 
are  now  developed,  and  put  the  patients  into  a  state  of  violent  agitation, 
during  which  they  become  dangerous  to  themselves,  to  those  around  them, 
a,nd  particularly  to  their  child.  Some  of  the  most  important  symptoms 
are  the  fancies  of  the  patients,  the  odor  which  they  exhale,  and  the  pres- 
ence of  albumin  in  their  urine.  Some  observers,  as  Marce,  attach  im- 
portance to  the  presence  of  erotic  ideas.  Puerperal  mania,  thus,  has 
nothing  peculiar  to  itself,  either  in  the  delirium  or  in  the  physical  symp- 
toms. 

Mania  terminates  in  recovery,  incurability  or  death.  Recovery  is  much 
the  most  frequent,  and  occurs  more  or  less  rapidly,  within  a  few  days  or 
several  months.  Among  the  complications  which  may  prove  fatal,  we 
should  accord  the  first  place  to  acute  delirium,  which  sometimes  begins 
with  the  attack,  but  sometimes  is  not  developed  until  after  several  weeks, 
or  after  a  paroxysm  of  duplex  insanity.  Instead  of  ceasing  in  a  few  days, 
acute  delirium  may  be  prolonged,  entering  a  new  stage.  Then  typhoid 
symptoms  develop,  syncope  occurs  and  the  patients  succumb,  either  sud- 
denly from  syncope,  or  slowly  with  all  the  symptoms  of  profound  nervous 
exhaustion.  To  recapitulate:  Patients  who  die  during  acute  puerperal 
mania,  succumb  either  to  an  intercurrent  disease  or  to  violent  agitation 
and  acute  delirium. 

Treatment. — Authors  have  recommended  venesection,  nauseating  doses 
of  tartar  emetic,  prolonged  warm  baths,  purgatives,  narcotics,  antispas- 
modics, camphor  and  the  milk  diet.  Marce  advises  prolonged  baths,  the 
expectant  treatment,  tonics  and  hydrotherapeutics. 

II.  Melancholia. 

This  is  less  grave  than  mania.  The  moral  state  of  the  woman,  during 
pregnancy,  seems  to  exert  a  special  causative  influence.  It  begins,  like 
mania,  either  within  a  few  days  after  delivery  or  near  the  sixth  week.  It 
is  rapidly  developed,  or  occasionally  sad  ideas  may  precede  the  invasion  of 
the  delirium,  and  of  the  melancholic  depression.     In  certain  cases,  there 


DISEASES    OF    PKEGNANCY.  171 

is,  for  some  days,  a  general  excitement  bordering  on  mania,  and,  later,  the 
delirium  becomes  liabitunl.  Ideas  of  persecution,  fear  of  death,  dread 
of  punishment,  and  ideas  of  suicide  form  the  basis  of  the  delirious  concep- 
tions. There  are  hallucinations  of  sight  and  of  hearing,  and  the  patients 
may  grow  dangerous  to  themselves  or  to  their  children.  Marce  reports 
analgesia,  hysterical  attacks  and  catalepsy  among  the  symptoms. 

Prognosis. — This  is,  generally,  not  very  grave,  but  the  duration  is  long, 
from  one  month  to  six  months. 

Treatment. — It  consists  in  prolonged  warm  baths,  cold  affusions,  opium, 
chloral,  hygienic  measures  and  constant  surveillance. 

Together  Avitli  these  two  chief  forms  must  be  mentioned  the  partial 
lesions  of  intelligence,  the  hallucinations  of  sight  and  of  hearing,  impul- 
sive religious  monomania  and  homicidal  monomania.  Marco  mentions  a 
special  variety  of  intellectual  enfeeblement,  which  is  prone  to  follow  abun- 
dant puerperal  hemorrhages,  may  be  general  or  partial,  and  particularly 
affects  the  memory.  Dementia  also  occurs,  and  lastly,  cyclical  or  duplex 
insanity,  characterized  by  two  regular  periods,  one  of  excitement,  of 
mania,  and  the  other  of  depression,  of  melancholia,  the  association  of 
which  constitutes  a  paroyxsm.  It  sometimes  follows  mania,  and  may  be 
intermittent.     It  is  a  secondary,  chronic  form  of  puerperal  insanity. 

III.  Insanity  of  JSfursing  Women. 

This  form  of  insanity  developes  during  the  first  six  or  seven  weeks  after 
labor,  or  later,  after  eight,  ten  or  twelve  months  of  lactation  or  even  a  few 
days  after  weaning.  The  disease  begins  in  two  ways,  either  suddenly, 
after  exciting  events,  chills,  etc. ,  or  gradually.  The  prevailing  tj^pes  are 
mania,  melancho],ia,  monomania  and  duplex  insanity.  The  prognosis  is, 
generally,  not  bad.  Marce  saw  twenty  cures  among  twenty-six  cases. 
The  cure  may,  however,  be  slow,  occurring  only  after  several  months  or 
years.  The  first  indication  is  to  stop  lactation.  To  accomplish  this, 
dieting,  purgatives,  the  iodide  of  potassium^,  and  after  suppression  of  the 
secretion,  a  tonic  regimen  may  be  useful. 

Diseases  of  the  Skin". 

Besides  the  regular  eruptions  of  pregnant  women,  there  is  often  ex- 
tremely severe  itching  of  the  skin,  without  visible  lesion.  This  itching, 
which  may  commence  at  the  beginning  or  not  until  the  second  half  of 
pregnancy,  may  reappear  during  consecutive  pregnancies,  (case's  of  Mas- 
lieurat  Lagemard.)  Sometimes  temporary  and  passing,  this  itching  is,  in 
other  cases,  rebellious  to  all  treatment,  and  only  disappears  after  labor. 
Although  not  grave,  it  becomes  the  source  of  annoyance  and  even  of 
weakness.  Being  aggravated  by  warmth  and  by  rest  in  bed,  it  thus  de- 
prives the  patients  of  sleep.  In  some  cases,  the  suffering  is  so  severe  that 
the  women  scratch  off  the  epidermis,  thus  adding  to  their  torture.     Often, 


172  A    TREATISE    OTST   OBSTETRICS. 

the  itching  is  confined  to  certain  regions  and  reappears  with  each  preg- 
nancy, so  regnlarly  that  the  patients  recognize  the  beginning  of  pregnancy 
by  this  sign.  Hebra  cites  the  case  of  a  woman  who  saw  this  itching  develop 
upon  her  fingers  after  the  fecundating  coitus,  in  seven  consecutive  preg- 
nancies. 

The  real  cutaneous  eruptions  usually  appear  in  the  first  months,  and 
then  either  disappear  before  labor,  which  is  the  exception,  or  at  variable 
periods  after  labor. 

The  most  common  of  these  skin  diseases  are  the  so-called  chloasma  of 
pregnant  Avomen— the  mask,  and  pityriasis  versicolor.  The  favorite  seats 
are  the  forehead,  the  cheeks  and  the  chin.  The  eruption  consists  of  yel- 
lowish spots,  more  or  less  extended,  but  not  reaching  beyond  the  limit 
of  the  hair.  Cazeaux  believes  that  light  is  one  of  the  chief  necessities 
for  their  development,  and  that  the  shadow  of  the  hair  suffices  to  arrest 
their  formation. 

Hardy  and  Hebra  separate  these  spots  into  two  species:  the  ephelides 
and  the  pityriasis. 

Hardy  says  that  the  ephelides  are  not  projecting,  and  are  not  attended  by 
pruritus  or  desquamation.  They  are  comjDosed  of  an  accumulation  of 
pigment  in  circumscribed  areas.  The  ephelides  often  develop  in  women 
at  the  time  of  menstruation,  and  particularly  during  pregnancy.  They 
generally  disappear  after  labor,  but  not  always,  to  the  despair  of  the 
patients. 

Hardy  advises  the  application,  twice  daily,  of  the  following  solution: 

Aquge  destillat.         .         .         .         .         .         .         .  fl.    3  iv. 

Hydrarg.  chlorid.  corrosiv.       .....  grs,  vii  ss. 

Zinci  sulphat.  .  .  .  .  .         .        *.  grs.  xxx. 

Plumb,  acetat.  .......  grs.  xxx. 

Alcohol,  qs.  ad.  sol. 

If  this  is  not  sufficient,  one  may  advantageously  employ  sulphur  waters, 
particularly  those  of  Luchon  and  Bareges,  locally  applied. 

Pityriasis  versicolor,  although  resembling  the  ephelides, dijEfers  essentially 
from  them  in  that  it  is  papular.  The  papules  are  covered  by  little  scales. 
This  eruption  is  always  accompanied  by  slight  itching,  and  is  a  parasiti- 
cal disease  occupying,  according  to  Hebra,  the  hair  bulbs.  The  micro- 
scojDe  facilitates  the  diagnosis,  showing  some  spores  and  numerous  ramifi- 
cations in  the  scales. 

The  treatment  consists  in  sulphur  lotions,  douches,  and  sulphur  oint- 
ments. Hardy  advises  sublimate  lotions  and  citrine  ointment.  Jeannin 
believes  in  an  intimate  relation  between  menstrual  troubles  and  this  erup- 
tion. It  is,  according  to  him,  due  to  the  arrest  of  the  menses,  and  preg- 
nancy is  not  indispensable  for  its  occurrence,  since  it  is  observed  in 
women  or  girls  who  have  not  conceived,  when  their  menstruation  is  dis- 
turbed.    He  does  not  believe  that  the  parasite,  microsporon  furfur,  is 


DISEASES    OF   PREGNANCY.  1  I  6 

indispensable,  but  it  maj^  be  observed,  which  justifies  tlie  classification  of 
Hardy.  Parrot  is  opposed  to  Jeannin,  in  that,  while  he  admits  that 
chloasma  may  bo  related  to  menstrual  disorders,  he  attributes  it  to  a  neu- 
ropathic condition,  finding  expression  in  certain  general  pigmentations  of 
the  skin. 

Hebra  mentions  acne,  or  inflammation  of  the  hair-follicles,  or  of  the 
sebaceous  follicles.  It  may  be  common  acne  or  acne  rosacea.  The  latter 
resists  all  treatment  until  after  labor.  In  some  women,  the  nose  is  the 
part  attacked,  and  it  becomes  red,  tumid  and  covered  with  the  pimples  of 
acne.  Again,  a  true  eczema  may  be  developed  in  the  early  stages  of 
pregnancy,  and  may  become  terribly-  severe,  as  in  one  case  of  our  own. 

Urticaria  is  another  eruption  affecting  pregnant  women,  and  may  reap- 
pear at  certain  hours  of  the  day,  after  meals  or  in  the  evening.  We  have 
seen  a  case  which  yielded  to  alkalies  and  quinine.  Hebra  has  seen  two 
cases  of  puerperal  pemphigus.  In  one  case  it  appeared  two  days  after 
labor,  and  there  was  no  relapse  in  later  pregnancies.  In  the  second  case, 
the  eruption  appeared  in  three  consecutive  pregnancies,  in  the  same 
woman.  The  first  time  it  came  at  five  months  and  disappeared  after 
labor.  The  second  time  it  appeared  at  three  months,  and  did  not  disap- 
pear until  a  month  after  labor.  The  third  time  it  became  chronic  and 
did  not  disajjpear.  The  woman  was  delivered  of  a  dead  child.  Klein  has 
seen  a  persistent  pemphigus,  which  reappeared  in  two  pregnancies.  He 
also  observed  impetigo  herpetiformis,  which  showed  itself,  in  five  cases, 
during  pregnancy  and  labor.  The  eruption  was  pustular.  The  pustules 
appeared  on  the  inside  of  the  thighs,  either  discrete  or  in  groups,  and 
thence  invaded  the  legs,  the  abdomen,  the  chest,  the  arms,  the  forearms, 
the  hands,  feet,  neck,  face  and  scalp.  The  eruption  came  out  in  crops 
and  was  attended  by  burning  fever  and  great  prostration.  Before  each 
eruption  there  w^as  a  chill  with  a  pulse  of  104°  and  a  temperature  of  105°, 
which  then  slowly  subsided.  There  was  diarrhoea  which  was  once  bloody. 
The  urine  was  acid,  dark-colored  and  contained  a  little  pus,  much  urea 
but  no  albumin.  Of  the  five  women,  three  were  delivered  from  two  to 
five  weeks  before  the  eruption,  two  were  attacked  in  the  last  months  of 
pregnancy,  and  were  delivered  at  the  hospital.  The  symptoms  remained 
unchanged  after  labor.  Among  the  five  women  four  died.  They  had 
no  puerperal  disease,  and  showed  no  trace  of  syphilis.  Yrain  reports  one 
case  of  erythemato- tubercular  scrophulide  of  the  face,  and  one  case  of  stru- 
mous lupus  during  pregnancy,  and  aggravated  by  subsequent  pregnancies: 
Eczema  of  the  face  and  hands,  3  cases;  of  the  scalp,  2  cases;  zona 
and  eczema  impetiginosa,  1  case. 

The  most  common  skin  disease,  with  pregnant  women,  is  certainly 
prurigo. 


174  a  treatise  on  obstetrics. 

Lesions  of  the  Pelvic  Akticulations. 
RelaxaUo7i  of  the  Symphyses. 

After  having  been  admitted^  then  contested,  then  demonstrated  by 
Severin  Pinand,  in  1869,  upon  the  body  of  a  woman  recently  confined,  the 
softening  of  fhe  inter-articular  cartilages  and  the  consequent  relaxation 
of  the  pelvic  symphyses  is  to-day  granted  by  all  obstetricians,  But  this 
softening  is  usually  moderate,  and  remains,  so  to  speak,  within  physio- 
logical limits.  Sometimes,  however,  it  is  so  extreme  as  to  become  patho- 
logical. Groing  still  farther,  Zaglas  has  recently  demonstrated  that  there 
is,  in  man,  a  perceptible  movement  of  the  ossa  innominata,  antero-poste- 
riorly,  or  around  an  imaginary  transverse  line  traversing  the  second  sacral 
vertebra.  So  we  may  consider  the  sacrum  as  having  a  movement  of 
rotation  around  an  imaginary  transverse  axis,  the  promontory  advancing 
forward  and  downward,  while  the  apex  moves  in  an  opposite  direction 
and  vice  versa. 

Matthews  Duncan  cavils  attention  to  the  presence,  on  the  posterior  arti- 
cular surface  of  the  iliac  bones,  of  an  irregular  bony  prominence,  which 
often  has  the  form  of  a  massive  angle  in  relief.  There  is  a  cavity  corre- 
sponding to  this  eminence  upon  the  opposite  side  of  the  sacrum,  and  the 
cavity  is  analogous,  as  regards  some  of  its  functions,  to  a  cotyloid  cavity. 
The  movements  of  the  iliac  bones  occur  at  the  level  of  these  surfaces,  which 
are,  generally,  opposite  the  upper  part  of  the  second  sacral  vertebra. 
While  they  offer  no  resistance  to  the  movements  of  flexion  and  extension 
of  the  ilia  upon  the  sacrum,  they  oppose  vertical  movements  between  the 
bones,  such  as  would  necessarily  be  prejudicial  to  stability  in  the  erect 
posture.  In  the  latter  half  of  pregnancy,  the  soft  parts  entering  into  the 
formation  of  the  joints  are  always  softened,  and  the  articulations  are  con- 
sequently relaxed.  The  softening  of  these  tissues  is  generally  accompanied 
by  increase  in  their  thickness,  which  produces  separation  of  the  bony  sur- 
faces and  widening  of  the  pelvic  diameters.  In  some  cases,  this  thicken- 
ing is  extraordinary.  Boyer,  Chaussier,  Bovin,  Smellie,  Dimerbroeck 
and  Denman,  have  reported  separations  of  the  bones,  even  to  the  exten- 
of  from  one-half  inch  to  an  incho  Matthews  Duncan,  thus  regards  the 
softening  and  thickening  of  the  ligaments  as  the  cause  of  separation  of  the 
joint  surfaces,  as  a  wedge  of  dry  wood,  becoming  moistened  by  the  absorp- 
tion of  water,  splits  stones  into  which  it  is  driven.  Lenoir  thinks  that, 
at  a  later  stage,  the  relaxation  depends  solely  on  the  serous  infiltration  of 
the  pelvic  ligaments,  due  to  pregnancy.  This  does  not  produce  separation 
of  the  articular  surfaces,  but  renders  it  possible  under  the  influence  of 
an  effort  tending  to  produce  it.  In  the  late  stages,  a  hypersecretion  of 
synovia  is  added  to  the  softening,  distends  the  cavities  and  separates  the 
bones.  Then,  the  mobility  is  very  great,  and  if,  in  the  cadaver,  one  opens 
the  joints,  a  viscid  abundant  fluid  escapes,  as  Morgagni  saw  in  one  case. 


DISEASES    OF    PREGNANCY.  175 

Trousseau,  Ferdinand  Martin,  and  Tarnicr  liave  again  called  attention  to 
this  relaxation  of  the  pelvic  joints,  and  Bourhis  and  Dubois  have  studied 
it  with  care. 

For  Stoltz,  this  relaxation  is  either  the  effect  of  softening  of  the  liga- 
ments, 01'  of  violence  exerted  upon  the  tissues  holding  the  pelvis  together, 
during  operations  undertaken  to  deliver  the  woman:  He  thus  makes  two 
classes  of  relaxations.  1.  The  slow  and  progressive  relaxation;  2.  The 
violent  and  sudden  relaxation.  This  latter  also  bears  the  name  of  rup- 
ture of  the  symphyses. 

Korsch,  in  the  laboratory  of  Professor  Slavjansky,  at  St=  Petersburg, 
examined  thus  forty- five  j)elves,  of  which  there  were:  Pelves  of  women 
dead  after  labor  at  term,  18;  before  term,  8;  after  an  abortion,  3;  before 
labor,  1.  Pelves  with  uterine  and  ovarian  tumor,  4;  pelves  of  women 
not  pregnant,  6  ;  pelves  of  men,  5.  The  following  are  his  conclu- 
sions: 

1.  The  influence  of  pregnancy  and  of  large  uterine  and  ovarian  tumors 
manifests  itself,  not  only  by  softening  of  the  ligaments  of  the  joints,  but  by 
enlargement  of  the  dimensions  of  the  inlet,  and,  particularly,  of  the  out- 
let. 

2.  At  the  inlet,  the  greatest  enlargement  occurs  in  the  transverse  diam- 
eter. The  reverse  obtains  at  the  outlet.  The  longitudinal  diameter  is 
less  elongated  than  the  transverse. 

3.  To  produce  enlargement  of  the  superior  strait,  almost  double  the 
force  is  necessary  as  for  the  inferior  strait. 

4.  The  elongation  of  the  transverse  diameter  of  the  inlet  involves  the 
shortening  of  the  conjugate.  However,  the  elongation  of  the  conjugate 
does  not  modify  the  transverse  diameter  (in  some  cases  we  obtain  a  short- 
ening of  about  one  twenty-fifth  of  an  inch). 

5.  The  maximum  elongation  of  the  transverse  diameter  of  the  inlet 
always  slightly  enlarges  the  conjugate.  But  the  maximum  elongation  of 
the  conjugate  does  not,  generally,  enlarge  the  transverse  diameter. 

6.  The  simultaneous  enlargement  of  both  diameters  of  the  inlet  never 
elongates  them  so  greatly  as  a  successive  enlargement  of  each  diameter. 

7.  The  widening  of  the  outlet  always  slightly  shortens  the  conjugate, 
and  slightly  elongates,  or  leaves  intact,  the  transverse  diameter  of  the 
superior  strait. 

8.  The  same  holds  true  of  the  outlet  when  the  inlet  is  widened. 

9.  In  most  of  our  cases  we  noticed  greater  mobility  in  the  ligaments  of 
the  sacro-iliac  and  sacral  articulations. 

10.  In  the  most  mobile  joints,  the  quantity  of  synovia  was  always  in- 
creased. 

11.  The  elongation  of  the  longitudinal  diameter  depends  on  the  mo- 
bility of  the  sacrum,  but  the  mobility  of  the  symphysis  particularly  aids 
increase  of  the  transverse  diameter. 


176  A    TREATISE    OlST    OBSTETRICS. 

12.  The  larger  the  crevice  or  cavity  of  the  symphysis  pubes,  the  greater 
the  mobility  of  this  articulation. 

13.  The  number  of  labors  seem  to  have  no  influence  upon  the  mo- 
bility of  the  pelvic  articulations. 

Causes. — The  temperament  of  the  patients  has  been  mentioned  as  a 
cause.  Feeble  and  delicate  women  are  supposed  to  be  more  predisposed 
than  others  (Munro,  Smellie),  and  Eoederer  has  even  said  that  debility^ 
rickets,  venereal  diseases  and  profound  cachexi^e  were  themselves  capable 
of  producing  relaxation  of  the  pelvic  ligaments.  Morgagni  opposed  this 
exaggerated  opinion.  The  influence  of  scrofula  is  not  more  manifest. 
Other  assumed  causes  are  extreme  youth  or  age  of  the  women,  and  the 
primiparous  and  multiparous  condition.  The  contradiction  of  these 
opinions  deprives  them  of  value.  Jacquemier  holds  that  the  relaxation 
of  the  symphyses  is  due  to  the  development  of  the  uterus,  particularly 
when  this  development  surpasses  ordinary  limits,  as  in  large  size  of  the 
foetus,  twin  pregnancy  and  hydramnion.  (But  there  are  cases  in  which 
the  relaxation  appeared  in  the  second  or  the  third  month. ) 

Excessive  exercise,  bodily  fatigue  and  anchylosis  of  the  knee  are  causes. 
Too  sudden  getting  up  after  confinement  has  been  accused  of  an  etio- 
logical relation. 

All  these  causes  are  problematical,  for  one  observes  relaxation  of  the 
articulations  in  women  belonging  to  all  classes  of  society,  and  the  eti- 
ology is,  really,  very  obscure. 

Eelaxation  of  the  symphysis  always  begins  during  pregnancy,  and,  in 
general,  in  the  seventh,  eighth  and  ninth  months,  but  it  may  commence 
much  earlier.  Moreau  has  seen  it  in  the  second  month  and  Desormeaux 
in  the  fifth.  In  two  cases  of  our  own,  the  disease  began  once  at  six 
months  and  once  at  seven  and  a  half.  The  disease  always  begins  insidi- 
ously, by  a  feeling  of  lassitude  and  weakness,  accompanied  by  pains  in 
the  lumbar  region,  which,  at  first  dull,  soon  grow  more  intense,  and  in- 
volve the  buttocks,  the  groins,  and  the  symphysis  pubes.  The  patients  at 
first  only  feel  them  when  walking,  then  in  the  standing  or  sitting  pos- 
ture, and,  finally,  in  some  cases,  they  become  so  pronounced  that  they  do 
not  cease  even  when  the  patients  assume  the  dorsal  decubitus,  and 
the  least  movements  become  so  painful  as  to  be  almost  impossible.  The 
pains  are  always  more  marked  at  the  sacro-iliac  joints  than  at  the  pubic 
symphysis.  They  are  often  accompanied  by  numbness  in  the  abdomen. 
When  the  patients  rise,  the  pains  become  very  violent  and  assume  a 
peculiar  character.  It  seems  to  the  women  as  if  the  pelvis  was  spreading 
apart,  their  bones  becoming  dislocated,  and  as  if  they  were  sinking 
between  their  haunches.  The  gait  becomes  almost  pathognomonic.  It 
consists  in  a  balancing  from  one  leg  to  the  other,  a  sort  of  oscillation. 
The  women  waddle  like  ducks.  In  walking,  the  women  sustain  their 
loins  with  their  hands,  now  bending  forward   and  now  backward.     At 


DISEASES    OF    PREGNAKCY.  177 

such  times  we  can  feel  the  bones  being  displaced^  and  when  we  attempt 
to  make  them  move  npon  eacli  other,  the  woman  resting  on  her  back, 
this  is  successful  up  to  a  certain  point.  If  we  feel  of  the  different  joints, 
we  excite  a  sharp  pain  in  them,  and  sometimes  can  observe  a  notable  dis- 
placement of  the  bones  at  the  symphysis  pubis.  Trousseau  related  a 
case  where  one  could  introduce  the  end  of  the  finger.  When  the  sepa- 
ration is  not  appreciable  to  the  touch,  we  may  recognize  it  by  a  proceed- 
ing which  we  often  saw  used  by  Depaul  before  Budin  again  called  atten- 
tion to  it  at  the  Biological  Society.  It  consists  in  placing  the  woman  in 
the  erect  posture,  against  a  resisting  object,  and  in  placing  two  fingers 
horizontally  beneath  the  symphysis  and  therefore  introduced  a  little  way 
within  the  vagina.  The  woman  is  now  made  to  stamp  the  feet  or  to  walk 
a  few  steps,  whereupon  the  fingers  applied  below  the  symphysis,  distinctly 
feel  the  oscillation  of  the  iliac  bones  at  this  level,  and  thus  ascertain 
the  mobility  and  the  widening  of  the  articulation 

When  once  begun,  the  relaxation  of  the  joints  goes  on  increasing 
until  the  time  of  delivery,  but  if  the  women  keep  quiet,  they  only  have 
their  movements  impaired;  their  general  health  is  unaffected.  It  is  not 
always  thus,  for  in  one  of  our  cases  the  pain  was  such  as  to  deprive  the 
patient  of  sleep,  and  thus  to  induce  notable  weakness  and  exhaustion. 
Generally,  this  articular  relaxation  disappears  after  labor,  but  sometimes 
it  persists  at  least  a  short  time,  and,  rarely,  for  months  or  even  years. 
Courty  quoted  a  case  which  lasted  two  years,  and  Baudelocque  one  of  nine 
months'  standing.  Lenoir  and  Robert  have  seen  the  malady  persist 
through  life.     In  one  of  our  cases  the  duration  was  eighteen  months. 

Sometimes  the  relaxation  becomes  complicated  after  labor,  with  in- 
flammation of  the  joints.  These  results  are  rare  in  slowly  progressive 
relaxation,  but  usual  in  the  sudden  relaxation  of  labor,  where  the  so- 
called  rupture  of  the  symphyses  occurs.  Only  one  affection  can  be 
mistaken  for  relaxation  of  the  joints.  This  is  inflammation  of  the  artic- 
ulations, and  we  will  soon  revert  to  that  subject. 

Prognosis. — This  should  always  be  considered  serious,  although  not 
absolutely  grave,  for  the  disease  predisposes  to  inflammations  of  the  sym- 
physes, and  to  their  rupture  during  labor.  It  may,  moreover,  persist  a 
long  time,  thus  constituting  a  real  cause  of  infirmity. 

Treatment. — This  must  not  be  neglected.  Although  rest  suffices 
most  of  the  time  in  slight  cases,  the  patients  should  be  carefully  watched 
after  confinement.  To  keep  the  patients  in  bed  for  a  very  long  time,  say 
one  month,  six  weeks  or  two  months,  if  necessary,  and  to  maintain  im- 
mobility of  the  articulations  are  the  first  indications.  In  many  cases  a 
towel,  a  body  bandage,  a  roller  bandage,  suffice.  In  others,  more  ener- 
getic restraint  is  necessary.  Boyer  advised  a  leather  girdle,  and  Martin 
a  complete  metallic  girdle,  quite  strong  and  large  enough  to  encircle  the 
entire  pelvis.  The  spring,  the  height  of  which  is  about  one  third  of  an 
Vol.  n.— 12. 


178  A    TREATISE    ON    OBSTETRICS. 

inch,  padded  and  trimmed  like  those  of  trusses,  is  interrupted,  anteriorly, 
and  furnished  on  one  side  with  a  strong  strap,  and  on  the  other  with  a 
buckle,  by  which  means  the  two  ends  are  approximated  and  iirmly  held 
in  contact.  We  saw  a  so-called  gymnastic  girdle  used  with  advantage 
in  one  case,  and  followed  by  a  plaster  dressing.  But,  as  Oazeaux  properly 
says,  we  must,  above  all,  be  certain  that  there  is  no  inflammation  of  the 
joints,  and  must  not  resort  to  restraining  measures  until  all  inflammation 
has  been  dispersed  by  revulsives.  It  is  well,  afterward,  to  use  sulphur 
douches,  which  rendered  us  great  service  in  one  case.  Patients  must  he 
careful  not  to  leave  off  their  apparatus  too  soon,  and  must  not  incur 
fatigue  by  taking  too  much  exercise. 

■    Inflammation  of  the  Articulations. — Inflammation  of  the  Symphyses. 

Although  generally  observed  after  labor,  inflammation  of  the  pelvic 
symphyses  may  appear  during  pregnancy,  and  to  the  cases  cited  by  Hiller, 
Monod,  Danyau,  Hayn,  Joyeux  and  Kiwisch,  we  can  add  two  observed  by 
ourselves.  Dubois  reported  three  more,  in  1879,  and  we  are  convinced 
that  it  would  be  easy  to  find  a  larger  number  still 

Causes.— KccoviMng  to  Fodere,  these  are,  particularly,  the  puerperal 
state,  scrofula,  rheumatism,  and  traumatisms  incident  to  labor 

Symptoms. — Generally,  the  disease  begins  a  few  days  after  labor,  from 
the  third  to  the  tenth  day,  sometimes  even  earlier,  in  grave  cases.  In 
some  cases,  the  characteristic  symptoms  of  relaxation  are  observed  toward 
the  end  of  pregnancy,  and  inflammation  manifests  itself  after  delivery, 
and  we  may  say  as  a  result  of  it.  Usually,  a  chill  opens  the  scene,  a  fever 
follows  and  then  the  characteristic  symptoms  appear.  The  first  is  ^Min, 
which,  slight  at  first,  grows  rapidly  worse,  is  increased  by  movements  and 
is  localized  in  the  joint  attacked.  Generally,  the  sacro-iliac  joints  are  at- 
tacked, and  the  pain  is  then  usually  more  violent  and  lasting.  From  the 
joint  the  pain  spreads  to  the  loins  and  the  buttocks,  radiating  also  into 
the  legs.  Sometimes  it  remains  fixed  in  the  articulation,  or,  at  least,  is 
augmented  by  slight  pressure  in  this  region  or  upon  the  iliac  crests. 
When  the  symphysis  pubis  is  attacked,  the  pains  are  less  severe,  and  are 
located  in  the  front  of  the  pelvis.  When  the  pain  radiates  into  the  legs, 
it  there  produces  sensations  of  formication  and  of  numbness,  and  the  sensi- 
bility of  the  limb  may  be  impaired  (cases  of  Joyeux  and  Pigeolet). 
Sometimes  the  pain  radiates  into  only  one  limb,  and  thus  simulates  sci- 
atica. This  happened  in  one  of  our  cases.  The  urinary  function  is  often 
impaired  when  the  symphysis  pubis  is  affected.  Sometimes  there  is 
dysuria,  and  sometimes  incontinence.  The  skin  over  the  joint  keeps  its 
.normal  color  for  some  time  but  often  becomes  red,  tense  and  shiny. 
Soon,  a  little  tumefaction  and  oedema  appear,  but  these  are  not  constant, 
and,  generally,  vaginal  palpation  is  necessary  to  detect  swelling  of  the 
articulation.     In  rare  cases  the  tumefaction  fluctuates,  an  abscess  forms. 


DISEASES    OF    PREGKANCY.  179 

grows  large  and  breaks  its  way  into  the  pelvis  or  outward .  In  the  former 
case  death  may  result,  and  at  the  autopsy  we  find  the  articular  surfaces 
altered  and  denuded  of  their  cartilage. 

Prognosis.  — This  is,  thus,  serious  enough,  although,  even  in  these 
cases,  a  cure  may  be  effected  and  the  disease  end  in  anchylosis.  Gener- 
ally, these  inflammations  cease  after  a  time. 

Treatment. — This  embraces  local  revulsives  and  venesections,  with  ab- 
solute repose  and  opiates. 

Rupture  of  the  Symiihyses. 

Sudden  relaxation  of  the  symphyses  may  occur  and  constitute  rup- 
ture of  the  symphyses. 

As  Bach  said,  in  1832,  "In  order  that  the  separation  of  the  sym- 
physes may  occur,  there  must  be  a  great  expansibility  of  the  articulations. 
If  this  expansibility  does  not  exist,  and  if  the  force  causing  the  relatively 
large  foetal  body  to  pass  through  the  pelvis  is  sufficient  to  separate  the 
pelvic  bones,  rupture  will  occur.  In  ordinary  cases,  the  pelvis  resists 
longer  than  the  head,  but  often,  the  overlapping  of  the  cranial  bones 
does  not  suffice,  and  we  meet  with  many  more  cases  of  rupture  of  the 
symphysis  in  labor  than  of  fractures  of  the  skull.  The  symphysis 
pubes  is  less  susceptible  to  rupture  than  the  posterior  articulations. 
We  meet  many  more  examples  of  rupture  of  the  sacro-iliac  articula- 
tions than  of  the  symphysis  pubes,  while  relaxation  of  the  latter  is  oftener 
seen. ' ' 

In  rare  cases,  spontaneous  rupture  may  occur  (Duverney,  An- 
siaux),  but  generally,  rupture  follows  the  use  of  the  forceps.  De  Lamotte 
quotes  a  case  of  rupture  from  version,  and  Chaussier  has  cited  a  similar  one. 
Bach  does  not  believe  that  rupture  can  occur  without  predisposition,  and 
it  is  also  necessary  that  relative  narrowness  exist  without  which  only 
separation  would  take  place.  Among  the  predisposing  causes,  he  cites 
failure  in  the  cohesion  of  the  ligaments  of  the  symphyses,  found  in 
cachectic  persons  and  in  rickets,  osteomalacia,  scrofula,  scorbutus,  gout 
and  syphilis.  Most  frequently,  the  rupture  takes  place  on  the  descent  of 
the  head  into  the  pelvis,  but  it  may  occur  at  the  time  of  the  extraction  or 
ex|3ulsion  of  the  head  from  the  inferior  strait.  When  rupture  occurs  in 
the  posterior  symphyses,  it  is  due  to  backward  displacement  of  the  sacrum. 
Hence  the  tendency  of  the  pubic  bones  to  approach  each  other  in  front, 
and  to  separate  behind.  When  the  rupture  is  at  the  symphysis  pubes, 
the  surfaces  are  separated,  leaving  an  interval  between  them,  and  there 
is,  also,  always  a  separation  of  the  sacro-iliac  Joints  at  their  anterior  part. 
The  sudden  stretching  of  the  ligaments  of  the  posterior  symphyses,  by  the 
separation  of  their  articular  surfaces,  the  retrocession  of  the  sacrum, 
the  separation  of  the  ilia,  cause  a  rupture  of  the  ligaments  maintaining 
these  bones  in  contact.     The  anterior  ligament  is  raised  and  made  tense. 


180  A   TREATISE    ON    OBSTETMCS. 

but  does  not  tear.     A  part  of  the  posterior  ligaments  is  torn  or  loosened, 
when  the  separation  is  sufficient. 

When  the  symphysis  pubes  is  involved,  the  inter-articular  fibro-cartilage 
and  the  anterior  ligament  are  torn,  the  posterior  ligament  is  elongated; 
sometimes  the  cartilage  of  incrustation  is  separated  from  one  of  the  bones, 
or  is  torn  off.  Bach,  who  has  seen  this  arrangement  at  the  symphysis 
pubes,  does  not  consider  it  possible  at  the  sacro-iliac  joints. 

Signs  and  Diagnosis. — If  rupture  occurs,  the  woman  feels  an  acute 
pain,  a  sense  of  laceration,  at  the  moment  when  the  head  passes  through 
the  inlet  or  outlet  of  the  pelvis.  Often,  there  is  a  cracking  sound,  per- 
ceptible to  the  assistants,  and  louder  when  the  symphysis  pubes  is  rup- 
tured. This  is  not  a  pathognomonic  sign,  however,  for  this  cracking 
sound  is  often  heard  without  rupture,  when  the  head  passes  a  contrac- 
tion of  the  pelvis.  The  obstetrician  then,  has  an  articular  sense  of  re- 
sistance overcome,  which  is  noticed  when  forceps  are  applied  at  the  inlet, 
in  pelvic  contractions.  It  is  then  due  to  the  depression  of  a  parietal 
bone  by  the  promontory.  In  rupture,  there  is  always  acute  pain,  which 
is  lacking  in  the  other  cases.  The  separation  is  never  so  marked  in  the 
posterior  articulations  as  at  the  pubic  symphysis,  but  the  pain  is  more 
severe.  At  the  latter  joint,  the  separation  is  often  considerable.  The 
pain  is  intensified  by  pressure  and  by  movements  of  the  legs.  Some- 
times there  is  a  real  crepitation.  After  from  twenty- four  to  forty-eight 
hours,  sometimes  later,  inflammatory  reaction  ensues,  and  the  symptoms 
of  inflammation  of  the  symphyses,  with  their  sequelse,  make  their  ap- 
pearance. 

PlIEEPERAL   EhEUMATISM. 

As  early  as  3866  and  1867,  Lorain  stated,  in  a  communication  made  to 
the  Medical  Society  of  the  Hospitals,  that  "there  exists  in  pregnant 
women  a  morbid  state  of  the  genito-urinary  passages,  which  may  pre- 
dispose to  attacks  ol:  arthritis,  analogous  to  blenorrhagic  arthritis.  There 
is  a  certain  amount  of  urethritis  as  well  as  of  cervicitis  and  vaginitis. 
The  urethral  pus,  as  well  as  the  pus  which  escapes  from  the  cervix  and 
bathes  the  vagina,  is  the  natural  result  of  pregnancy.  There  is  always 
disease  of  the  genito-urinary  organs  in  the  pregnant  woman.  Genital 
rheumatism  is,  thus,  as  little  surprising  in  her  case  as  in  that  of  a  man 
who  has  just  had  the  sound  passed. " 

Lorain's  ideas  have  been  reasserted  by  two  of  his  pupils,  in  their  in- 
augural theses.  Vachee  gives  the  name  of  uro-genital  rheumatism  to  this 
form  of  rheumatism,  and  states  that  it  may  occur  in  four  forms:  1.  As 
hydrarthrosis;  2.  Rheumatism,  proper;  3.  The  form  characterized  by 
vague  pains;  4.   The  nodular  form. 

Vaille,  in  1867,  takes  a  broader  view  than  Cruveilhier,  who  considers 
the  rheumatism  of  pregnant  women  to  be  akin  to  puerperal  rheumatism 


DISEASES    OF    PREGNANCY.  181 

proper  (i.e.,  the  rheumatism  which  is  developed  a  few  days  before  or  after 
labor),  and  adds  to  this  class,  menstruation,  which  he  considers  to  be  a  sort 
of  miniature  puerperal  state,  and  lactation.  He  describes  two  varieties 
of  puerperal  rheumatism — muscular  rheumatism  and  articular  rheuma- 
tism. Under  the  term  muscular  rheumatism  he  describes  tetany  or  con- 
'  tracture  of  nursing  women,  and  ordinary  muscular  rheumatism,  which 
seems  to  have  nothing  special  about  it,  excepting  its  causative  relation  to 
the  puerperal  state.    The  conclusions  he  arrives  at  are  the  following: 

1.  There  is  a  rheumatism  peculiar  to  the  puerperal  state,  developed 
under  its  influence  and  modified  by  it.  This  rheumatism  is,  perhaps, 
constantly  accompanied  by  leucorrhceal  or  other  dissharges,  and  is, 
therefore,  analogous  to  blenorrhagic  rheumatism.  This  is  Lorain's  geni- 
tal rheumatism. 

2.  Puerperal  rheumatism  attacks  the  same  organs  as  ordinary  rheu- 
matism. It  may  be  muscular  or  articular  and  may  provoke  other 
arthritic  diseases,  cardiac  affections,  meningitis,  ophthalmia,  erythemata, 
etc. 

3.  During  pregnancy  it  tends  to  follow  the  subacute  course  of  gon- 
orrhoeal  rheumatism.  It  is  prone  to  produce  hydrarthrosis,  and  may, 
rarely,  end  in  suppuration  or  white  swelling. 

4.  Immediately  after  labor,  particularly  when  epidemic  influences  are 
prevalent,  articular  rheumatisms  of  exceptional  gravity  may  be  devel- 
oped, and  are  remarkable  for  their  tendency  to  suppurate  and  to  pro- 
duce articular  changes. 

5.  Endocarditis  may  develop,  sometimes,  in  the  puerperal  state,  even 
when  there  is  no  joint  trouble. 

Braunberger,  in  1870,  stated  that  the  puerperal  state  is  only  one  of  tbe 
phases  of  Lorain's  genital  state,  and  that  the  rheumatoid  symptoms  of 
pregnancy  are  localized  in  the  joints  and  synovial  sheaths,  with  or  without 
the  coincidence  of  cardiac  affections.  This  local  trouble  is  tenacious,  re- 
bellious, aggravated  as  time  elapses  after  conception,  and  is  not  improved 
or  cured  until  after  parturition.  These  joint  troubles  of  pregnancy  have 
a  special  stamp.     They  are  quite  analogous  to  gonorrhoeal  arthritis, 

Peter  does  not  so  absolutely  admit  the  influence  of  these  causes.  "He 
thinks  that  everything  is  an  exciting  cause  of  rheumatism,  as  well  cold, 
which  is  a  general  traumatism,  as  a  contusion  which  is  a  local  one;  as  well 
urethral  gonorrhoea  as  uterine  gonorrhoea;  as  well  pregnancy  as  parturi- 
tion. " 

Tison,  in  1879,  admits  that  pregnancy  acts  in  two  ways:  1.  By  the 
profound  changes  which  conception  produces  in  the  general  condition 
and  in  the  woman's  health;  2.  By  the  discharges  which  exist  in  most 
cases. 

We  fully  concur  in  Peter's  opinion,  and  although  we  admit  that 
rheumatism  presents  some  peculiarities  in  pregnancy  and  the  puerperal 


182  A    TEEATISE    ON"   OBSTETRICS. 

state,  we  do  not  think  that  it  can  be  regarded  as  identical  with  gonor- 
rhoea! rheumatism,  and  we  believe,  much  more,  in  the  general  inflnence  of 
the  puerperal  state  than  in  a  local  influence  brought  about  by  the  vaginal, 
urethral  and  uterine  discharges  of  the  pregnant   woman. 

Symi^toms. — The  disease  often  begins  with  chills,  which  may  be  several 
times  repeated  and  which  are  generally  slight.  In  some  cases,  on  the 
contrary,  they  are  very  violent.     At  other  times  they  are  absent. 

Pain  generally  succeeds  the  chill.  Sometimes  very  intense,  it  is,  so  to 
speak,  the  initial  symptom.  Sometimes  it  is  dull  and  only  excited  by 
movements  or  pressure.  In  cases  of  great  intensity  it  has  been  observed 
to  persist  during  several  weeks,  with  the  same  severity,  thus  depriving 
the  patients  of  all  repose  and  of  all  sleep.  It  then  corresponds  to  the 
painful  form  of  Vachee  and  of  Fournier.  Now  fixed  in  one  joint,  now 
migratory,  it  is  soon  accompanied  by  marked  swelling  of  the  affected 
joints,  due  to  the  serous  effusion  into  these  and  to  inflammation  of  the 
peripheral  fibrous  tissues  and  of  the  bones  themselves.  Generally,  these 
pains  are  more  migratory  than  the  swelling,  which,  once  fixed  upon  a 
joint,- lasts  much  longer  than  the  pain  and  seems  to  persist  for  a  certain 
time  after  the  cure. 

Seat.  — The  disease  may  affect  many  joints,  to  a  variable  degree.  It  is, 
howevei",  rarely  erratic  and  generally  fixes  itself  upon  one  joint,  particu- 
larly the  knee,  the  elbow,  the  wrist  or  the  ankle.  There  is,  ordinarily, 
neither  redness  nor  heat,  but  the  articulations  attacked  are  swollen,  pasty, 
shiny,  of  a  pale  or  violet  color,  or  sometimes  devoid  of  color.  There  is 
a  sort  of  characteristic  obscure  oedema,  accompanied,  where  the  serous 
effusion  is  pronounced,  as  in  the  knee,  by  an  elevation  of  the  patella  and 
a  real  fluctuation.  At  the  same  time  the  febrile  reaction,  which  exists 
at  flrst,  yields  quite  rapidly,  and  the  disease  more  resembles  a  hydrar- 
throsis than  a  true  rheumatism.  The  temperature  rarely  exceeds  102°  F. 
The  sweats  are  not  profuse,  and,  although  the  patients  lose  some  strength 
and  grow  pale,  pregnancy  still  pursues  its  regular  course,  except  in  rare 
instances.  Generally,  the  rheumatism  of  pregnancy  is  subacute,  in- 
vading, at  first,  three  or  four  joints  and  then  settling  in  one  of  them, 
while  the  general  symptoms  disappear.  The  swelling  and  pain  on  pres- 
sure constitute  the  disease.  Often,  rheumatism  is  chronic  from  the 
first.  The  fever  is  hardly  noticed;  at  first,  the  swelling  and  discomfort  are 
confined  to  a  single  joint,  the  swelling  is  pasty,  and  the  color  of  the  skin 
unchanged.  We  have  noted  two  or  three  examples.  In  these  cases,  the 
disease  is  indefinitely  prolonged. 

Among  the  twenty-three  cases  reported  by  Tison,  the  disease  lasted 
from  1  month  to  l-J  months,  5  times;  from  2  to  3  months,  4  times;  from 
4   to  5  months,  4  times;  from  5  to  6  months,  4  times. 

In  one  of  his  cases,  Tison  saw  three  attacks  of  rheumatism  developed  in 
the  same  woman,  the  first  before,  the  second  during  and  the  third  after 


DISEASES    OF    PREGXANCY.  183 

pregnancy.  The  first  lasted  fifteen  days,  the  second  five  months  with 
endocarditis,  the  tliird,  also  with  endocarditis,  several  weeks. 

Terminations. — Among  Tison's  twenty- three  cases,  there  was  only  one 
death,  aiid  in  that  case  there  was  metro-peritonitis.  Eecovery  is  the 
rule,  but  recovery  with  anchylosis.  Tison  has  seen  it  eleven  times  out  of 
thirteen  cases,  three  of  them  with  nodosities;  in  four  cases,  stiffness  and 
swelling  remained;  three  times  the  patients  left  the  hospital  uncured;  in 
only  five  cases  was  the  cure  complete.  Sometimes  labor  causes  great  im- 
provement, but  at  other  times  it  has  no  influence  on  the  rheumatism. 
Whatever  Vaille  says,  the  termination  by  suppuration  is  rare  in  preg- 
nancy, but  not  rare  after  labor. 

Prog7iosis. — This  is  grave,  for  although  life  be  not  endangered,  anchy- 
losis follows  in  two -thirds  of  the  cases,  and  complete  recovery  occurs  in 
only  one- quarter  of  the  cases.  It  is  graver  in  proportion  as  the  disease 
was  localized,  at  first,  and  has  lasted  a  long  time. 

Treatment. — This  must  be  energetic,  consisting  of  quinine,  salicylate 
of  soda,  narcotics  locally,  and,  especially,  fixation  in  splints  or  immovable 
apparatus,  perforated  so  as  to  allow  of  the  application  of  medicinal  sub- 
stances. When  the  fever  has  passed,  revulsives  are  to  be  nsed.  The  tinc- 
ture of  iodine,  cotton  saturated  with  iodine,  vesicatories  and  the  actual 
cautery  may  be  employed.  Trousean  nsed  a  poidtice  composed  of  four 
pounds  of  bread,  six  and  a  quarter  ounces  of  camphorated  alcohol  and 
thirty  grains  of  the  extract  of  henbane.  A  poultice  is  thus  made  upon 
which  is  spread  one  hundred  and  fifty  grains  of  the  extract  of  belladonna, 
with  which  the  limb,  reposing  on  a  splint,  is  enveloped.  The  poultice  is 
only  renewed  once  in  eight  days.  To  prevent  it  from  drying,  it  is 
covered  by  a  sheet  of  oiled  silk.  The  whole  is  covered  with  cotton-batting 
and  held  by  a  bandage. 

Alkaline  baths  and  sulphur  douches  are  useful,  when  swelling  and 
stiffness  of  the  joints  are  the  only  remaining  symptoms.  The  patients 
are  not  to  be  kept  quiet  too  long.  It  is,  therefore,  good,  although  the 
limb  be  left  in  the  splint  most  of  the  time,  to  take  it  out  morning  and 
evening,  when  the  acute  attack  has  once  passed,  and  to  subject  it  to  a 
few  slight  movements,  limited  to  the  joint. 

One  sometimes  sees,  in  pregnancy,  true  gonorrhoeal  rheumatism,  syphi- 
litic rheumatism,  such  as  Dubois  and  Fournier  have  reported,  and  white 
swellings.  White  swellings  may  exist  before  pregnancy,  or,  as  in  a  case 
of  Labbe,  quoted  by  Dubois,  the  white  swelling  developed  in  the  left 
knee  during  the  puerperal  state  of  a  preceding  pregnancy,  pursued  its 
course  and  necessitated  amputation  during  a  subsequent  pregnancy. 
The  patient,  already  pregnant  three  months,  submitted  to  amputation 
and  recovered  without  an  abortion.  In  another  case,  quoted  by  Eichet, 
there  was  white  swelling  of  the  wrist  and  of  the  right  knee.  Eichet  em- 
ployed igni-puncture.     A   month  later    the  patient  was  attacked  with 


184  A    TREATISE    ON    OBSTETRICS. 

acute  tuberculosis.  Slie  was  delivered  at  eight  months  and  died  forty- 
eight   hours  afterward. 

After  Confinement. — Braunberger  is  very  wrong  in  uniting,  under  a 
single  heading,  rheumatoid  symptoms  occurring  after  labor,  although 
he  carefully  divides  them  into  three  distinct  classes:  1.  Articular  locali- 
zations in  subacute  infectious  puerperal  troubles;  2.  Articular  localiza- 
tions in  acute  infectious  puerperal  troubles;  3.  Localizations  in  non- 
infectious chronic  puerperal  troubles.  Here  we  have  incontestable  con- 
fusion. 

We  must/ indeed,  carefully  distinguish  rheumatic  disease — developed 
in  the  normal  course  of  the  puerperal  state,  and  the  arthritis  of  puer- 
peral fever,  which  Lorain  and  Quinquaud  have  called  the  infectious  puer- 
peral state.  This  arthritis,  we  consider,  as  do  Lorain  and  Quinquaud, 
as  the  manifestation  of  puerperal  septicaemia  which  attacks  the  joints  as 
well  as  the  lymphatics,  the  veins,  the  serous  membranes,  the  heart  and 
all  the  other  organs,  and  is  either  primarily  or  secondarily  developed. 
But  these  symptoms  have  no  relation  to  rheumatism.  This  arthritis  may 
become  purulent,  the  same  as  puerperal  peritonitis  and  pleuritis,  but 
has  no  connection  with  puerperal  rheumatism.  Eheumatism  may,  of 
course,  be  developed  in  the  puerperal  state,  just  as  in  pregnancy,  and, 
when  it  does  so,  it  has  characteristic  features.  It  may  be  muscular, 
which  is  rare,  or  articular,  which  is  common. 

Musciclar  Rlieitmatism. 

This  form  attacks  the  muscles  of  the  upper  or  lower  limbs,  localizing 
itself  in  the  muscles  of  the  arms  or  of  the  calves.  To  the  two  cases 
cited  by  Warmont  and  observed  in  I^egroux's  service,  we  can  add  two 
seen  by  ourselves,  one  of  which  is  now  under  observation.  Confined  to 
the  calf,  in  our  two  cases,  the  disease  showed  itself,  each  time,  from  the 
twentieth  to  the  twenty- fifth  day  after  labor,  and  we  might  have  considered 
it  plilegmasia  alba  doUns  had  not  the  absence  of  fever  and  of  oedema,  and 
the  limitation  of  the  disease  to  a  small  area,  removed  all  doubt.  We 
should  prefer  to  call  the  trouble  myodinia  of  puerperal  women,  as  War- 
mont and  Legroux  do.  In  our  first  case  every  symptom  disappeared  at 
the  end  of  five  days,  by  the  application  of  belladonna  and  indulgence  in 
rest.  Our  second  patient  has  only  been  sick  three  days.  We  have  just 
seen  a  third  case,  where  the  rheumatism  had  settled  in  the  muscles  of  the 
left  shoulder  after  having  affected  the  corresponding  muscles  on  the  right 
side  for  forty-eight  hours.  The  patient  had  been  confined  twenty-four 
days  before.  The  disease  disappeared  in  eight  days,  under  quinine  and 
local  narcotics. 

Artimilar  Rheumatism. 

The  characteristic  of  these  cases  is  their  tendency  to  suppuration.  The 
joint  symptoms,  appearing  from  the   second   or  third  to  the  tenth  or 


DISEASES    OF    PREGNANCY.  ib;j 

fifteenth  day  after  confinement,  are  generally  accompanied  by  a  claret  red, 
a  blue,  or  a  pale  rose  color,  disppearing  on  pressure,  to  soon  return.  The 
swelling, unlike  that  observed  during  pregnancy,is  generally  slight,although 
the  efl:usion  be  more  abundant.  The  pain  is  excruciating.  The  pulse  is 
very  rapid,  from  one  hundred  and  ten  to  one  hundred  and  thirty-two 
per  n^inute.  The  temperature  usually  keeps  pace  with  the  pulse,  rising  to 
104°  or  even  106°  F.  Chills  are  frequent  and  recurrent.  In  fatal  cases, 
there  is  adynamia  and  delirium,  wbile  meningitis  is  a  frequent  complica- 
tion.    Pericarditis  and  endocarditis  are,  also,  complications. 

Fonsart  and  Bourdon  have  reported  teno-synovitis,  involving  both  the 
extensors  and  flexors  of  the  fingers  and  toes.  In  many  cases  peritonitis, 
peri-metritis  and  metritis  have  been  observed.  It  is  not  only  after  normal 
labor  at  term  that  puerperal  rheumatism  may  manifest  itself,  for  Peter 
has  reported  a  fatal  case  which  followed  an  abortion  at  three  months. 

The  prognosis  is  rendered  grave,  of  course,  by  the  tendency  to  suppura- 
tion already  alluded  to,  and  the  outlook  is  more  serious  in  proportion  as 
the  disease  has  developed  rapidly  after  labor.  But,  although  the  prog- 
nosis is  more  favorable  in  the  cases  occurring  later  than  the  tenth  or 
twelfth  day  after  labor,  it  is  still  very  serious,  for,  in  these  cases,  the 
arthritis  tends  to  chronicity,  and  the  termination  by  transformation  into 
strumous  arthritis  is  frequent.  In  the  most  favorable  cases,  anchylosis  is 
the  rule.  This  is  not  always  the  result,  and  in  one  case  which  we  ob- 
served at  the  clinic,  the  patient  recovered  without  suppuration  of  the 
articulations  and  without  anchylosis. 

Treatment. — This  is  often  inefficacious.  Quinine  seems  to  have  yielded 
the  best  results,  thus  far,  but  large  doses  must  be  used,  as  twenty-three 
grains  per  diem,  and  must  be  continued  during  the  whole  course  of  the 
disease.     The  treatment  should  not  be  suddenly  but  gradually  suspended. 

Kevulsives  and  narcotics  are  only  uncertain  palliatives. 

Chorea. 

Chorea  may  occur  during  pregnancy  or  after  labor,  but  is  infinitely 
more  common  during  utero-gestation,  and  this  relation  between  chorea 
and  pregnancy  had  been  already  noted  in  the  eighteenth  century  when 
Borsieri  advised  the  use  of  quinine. 

Frequency. — The  disease  is  rare,  for  Hosier,  in  1862,  had  only  been 
able  to  collect  twenty  cases.  Barnes,  in  1869,  collected  fifty-six,  and 
Fehling,  in  1874,  sixty-eight  cases.  Schroeder  and  Spiegelberg  consider 
it  as  very  rare.  The  latter  has  only  seen  two  cases,  in  a  very  large 
practice.  Among  1600  patients,  observed  by  ourselves  at  the  clinique, 
we  only  discovered  two  cases,  and  we  have  recently  seen  our  third  case  in. 
a  woman  after  labor. 

Causes. — 1.  Prmiijjarous  state. — All  authors  agree  on  this  point. 
Scanzoni,   Dreyssig,    Schneider,   Bezold,  Wirke,   Bodo,  Wenzel,  Sieckel, 


186 


A   TREATISE    01^   OBSTETRICS. 


Weber,    Russell  and    Spiegelberg  are  unanimous  on  this  question.     But 
the  only  authors  who  have  given  figures  are: 


Mosler,     . 

Barnes,    . 

Fehling,   . 
Charpentier, 


(  Primiparse, 

20  cases,  -<  Multiparas, 

(  Unknown, 

iPrimiparse, 
Multiparas, 
Unknown, 

58  cases,  i  ^P^^V^^^> 
3  cases. 


.  7 

.  5 

.  28 

.  15 

.  13 

.  33 

1  Multiparge  and  unknown,  35 

j  Primiparse,      .         .         .2 

--  -  ■                          .         .  1 


Multiparge, 

2.  Age. — Mosler,  among  twenty-one  cases,  found  sixteen  in  which  the 
age  was  exactly  known.     This  tabie  exhibits  the  ages: 


17  years, 

18  " 

19  " 

20  " 

23  '■' 

24  " 


a 


1  case, 

2  cases,  \-  Erom  17  to  20  years,    5  cases. 

2  "       ) 
5 

3  ''       [  From  20  to  24  years,  11  cases. 


Barnes  found  among  fifty-six  cases: 


17  years, 

18 

19 

20 

21 

22 

23 

24 

28 

32 

35 


3  cases, 


From  17  to  20  years,  11  cases. 


4     "       V 

4     ''       ) 

10     "      ^ 

1  case,    I 

2  cases,  J>From  20  to  24  years,  23  cases. 


1  case. 
1     " 
1     " 


J 


From  28  to  35  years,    3  cases. 


Chorea  is,  therefore,  most  frequent  between  20  and  25  years. 

3.  Giiistitution. — There  is  no  uniformity.  Sometimes  the  women  are 
feeble,  small  and  delicate,  and  sometimes  are  robust  and  strong. 

4.  Heredity. — Romberg  has  only  quoted  one  case  in  which  this  cause 
can  be  really  assumed. 

5.  Previous  Ghoi^ea. — Mosler  saw,  among  his  twenty-one  cases,  five  who 
had  had  previous  attacks.  This  was  noted  by  Senhouse  Kirke,  Eliscrhe 
and  Fehling,  fifteen  times  among  thirty-three  primipara?.  Barnes  reports 
nine  out  of  his  fifty-six  cases.  Spiegelberg,  without  giving  statistics,  in- 
sists on  this  point  and  the  same  is  true  of  Franck  and  Duncan,  whose 
patients  had  had  chorea  either  during  infancy,  as  in  the  preceding  cases, 
or  during  previous  pregnancies.  Chorea  may,  however,  appear  suddenly 
during  the  second  or   third  pregnancy,    or  as  a  relapse,   having    existed 


DISEASES    OF    PKEGNANCY.  187 

during  a  first  or  a  second  pregnancy.  Again,  it  may  not  appear  until 
after  labor  whether  at  or  before  term.  Pregnancy  may  commence  during 
an  attack  of  chorea,  as  in  a  case  of  John  Hirks. 

Among  the  seven  multiparae  cited  by  Hosier,  the  previous  pregnancies 
had  been  normal  in  throe,  and  in  two  there  had  already  been  chorea 
during  the  first  pregnancy.  In  the  other  cases  there  had  been  vertigo, 
intense  headache,  and  marked  anaemia. 

G.  Emotions,  as  anger,  fright,  mental  trouble,  delirium. 

7.  Eheicmatism. — Spiegelberg  insists  on  rheumatism,  combined  with 
cardiac  affections.  In  some  cases,  albuminuria  or  glycosuria  has  been 
noted.  In  many  cases  the  cause  is  not  discovered,  and  Spiegelberg  regards 
these  cases  as  reflex  neuroses,  which,  given  a  predisposition  on  the  patient's 
part,  suddenly  develop  under  the  influence  of  inadequate  nutrition  of  the 
nervous  centres  by  impoverished  blood  or  under  the  influence  of  peri- 
pheral irritation  of  the  genital  system.  It  is,  in  fact,  not  rare  to  find 
choreic  patients  poorly  nourished,  feebly  developed  and  anaemic.  Barnes, 
Copland,  Eoger,  See  and  Chambers  also  mention  rheumatism,  and  Ogle 
embolism. 

Period  of  Development. — Chorea  may  appear  at  any  stage  of  pregnancy 
and  after  labor,  but  it  is  particularly  in  the  earlier  part  of  pregnancy 
that  it  is  most  often  observed.  It  then  persists,  generally,  until  the  be- 
ginning, or  even  to  the  end  of  labor.  More  rarely,  it  yields  before  labor, 
and  more  rarely  still  (only  three  times  out  of  Spiegelberg 's  sixty-nine 
cases)  does  it  persist  during  the  post-puerperium.  In  our  own  case,  the 
chorea  did  not  appear  until  three  weeks  after  labor.  On  the  day  follow- 
ing her  confinement  the  patient,  a  multipara  who  had  been  four  times 
pregnant,  was  seized  with  a  left  crural  neuralgia  which  resisted  quinine, 
injections  of  morphia  and  vesicatories  for  twenty-one  days.  On  the 
twenty-second  day,  after  a  severe  annoyance,  the  patient  was  attacked  by 
left  hemichorea  of  a  typical  character,  involving  the  whole  left  side,  more 
marked  in  the  upper  extremity  and  involving  the  muscles  of  the  face. 
This  attack  disappeared  at  the  end  of  thirteen  days  and  gave  place  to 
genuine  hysterical  attacks,  which  were  repeated  two  or  three  times  daily, 
at  first,  but  which  are  nevertheless  now  diminishing.  There  is  now  only 
one  daily  hysterical  attack,  and  this  is  less  violent,  although  accompanied 
by  very  plain  erotic  sensations,  which  lead  to  free  secretion  of  the  vulvo- 
vaginal gland,  and  they  have  tended,  ever  since  their  diminution,  to  be 
replaced  by  an  incessant  hysterical  cough.  Bromides,  valerian,  cold 
douches  and  chloral  have  been,  hitherto,  absolutely  powerless,  and  the 
same  has  been  true  of  quinine,  arseniate  of  iron,  etc.  We  may  add  that 
the  patient  has  had  an  intense  catarrhal  metritis  for  some  years,  and  an 
ulceration  of  the  cervix  for  Avhich  she  is  now  being  treated.  She  had 
an  attack  of  chorea  in  her  infancy,  but  not  in  her  other  pregnancies. 


188 


TREATISE    0]Sr    OBSTETRICS. 


Eegarding  the  exact  date  of  the  attack,  Mosler  has  seen,  among  twenty- 
one  cases: 

In  the  first  2  months, 
''     "    3d  and  4th  months, 
''     ''    5th  "    6th        "         . 
"     "    last  months, 
Unknown,  .         . 

Among  fifty-seven  cases,  Barnes  found: 
In  the  1st  month,     3  times. 


7 

times 

.     8 

iC 

.     3 

11 

.     once. 

.     2 

2d 

3d 

4th 

5th 

6th 

7th 

8th 

9th 


3 

10 

7 
7 
4 
3 
2 
2 

41 


y  In  the  first  five  months,  30  times. 


J 


In  the  last  four  months,  11  times. 


Early,  without  exact  date,  6;  late,  3;  unknown,  6. 

Our  three  cases  appeared  as  follows  :  Twice  during  pregnancy,  at  the 
fourth  and  the  sixth  month,  and  once,  twenty-two  days  after  labor. 

In  Fehling's  fifty-five  cases,  chorea  began  in  the  first  half  of  pregnancy 
in  thirty-nine  instances.  In  only  three  did  the  chorea  persist  during  the 
puerperium.     In  only  twenty-nine  cases  did  pregnancy  reach  full  term. 

S(/m2Jto7ns.— These  vary  according  as  the  chorea  appears  slowly  or  sud- 
denly. If  the  inception  is  gradual,  the  friends  of  the  patient,  or  the 
patient  herself,  first  perceives  involuntary  movements  of  the  limbs  or  of 
the  face,  and  in  some  cases,  such  as  Kiwisch,  Scanzoni  and  Eomberg  have 
observed,  there  is  also  head-ache,  vertigo,  a  queer  facial  expression,  ex- 
cited speech,  and,  rarely,  excitement  of  the  whole  psychical  system. 
Then  these  movements  grow  marked,  and  the  chorea  is  progressively  de- 
veloped. At  other  times,  the  chorea  begins  rapidly,  the  incoordination  of 
the  movements  is  marked  and  rapidly  extends  to  several  parts  of  the  body. 

Among  the  twenty-one  cases  of  Mosler,  the  disease  began  in  the  right 
arm  alone,  twice;  in  the  left  arm  and  leg,  twice;  in  the  legs  only,  twice. 
The  attacks  returned  at  a  fixed  time.  In  four  cases  the  disease  began  in 
the  face,  and,  in  one  case,  in  the  tongue  muscles. 

When  the  attack  is  sudden,  several  parts  of  the  body  are  simultane- 
ously involved,  as  the  face,  limbs  and  tongue.  There  are  evening  exacer- 
bations, delirium  and  insomnia  (Helfft).  In  the  majority  of  cases,  the 
chorea  is  bilateral  (Mosler,  Fehling,  Barnes).  In  sixteen  of  Mosler's 
cases,  the  disease  affected  besides  the  limbs,  the  face,  the  eyes,  the  tongue, 
and  the  muscles  of  the  neck  and  trunk.  Speech  was  affected.  But  even 
in  these  cases,  the  chorea  is  not  always  of  equal  intensity  in  all  parts  of 


DISEASES    OF    PREGNANCY. 


189 


the  body,  and  the  movements  are  now  violent,  now  quite  slight.  In 
many  cases  there  seem  to  come  crises  or  exacerbations  of  the  disease. 
Almost  always,  save  in  two  cases  of  Franck  and  Ingleby,  the  movements 
ceased  during  sleep,  but  often-times  the  sleep  is  disturbed,  and  ac- 
companied by  night-mare.  The  patients  talk  aloud  and  are  restless. 
The  movements  reappear  in  the  morning  when  the  patients  awaken,  and 
sometimes  it  is  the  reappearance  of  the  movements  which  puts  an  end 
to  sleep  (Scanzoni).  There  are,  sometimes,  diurnal  remissions,  of  which 
Hosier  has  noted  four  distinct  cases.  Hand  has  observed  an  aggravation 
of  the  movements  under  the  influence  of  movements  of  the  child  and  of 
vaginal  touch.  Often,  the  chorea  is  accompanied  by  epileptiform  con- 
vulsions and  hysterical  fits  which  seem  to  return  at  fixed  hours  (Hosier, 
Duncan).  One  of  Duncan^s  patients,  and  one  of  our  own,  had  ulceration 
of  the  cervix.  Other  complications  are  headache,  sharp  pains  in  one 
limb,  cardiac  and  renal  diseases.  Generally,  there  is  little  or  no  fever,  no 
digestive  difficulties  and  no  disorder  of  the  intellect.  In  a  case  of  Lever, 
however,  there  was  weakening  of  the  memory  and  the  intelligence  seemed 
impaired  at  the  time  of  the  crises. 

Course,  Duration  and  Terminations. — The  influence  of  chorea  upon 
pregnancy  is  very  marked.  Abortion  or  premature  labor  are  common. 
The  sooner  the  chorea  begins,  the  greater  the  chances  that  pregnancy  will 
end  before  full  term. 

Among  twenty-one  cases.  Hosier  observed  four  abortions,  at  four,  five 
and  six  months.  In  three  cases,  the  chorea  had  lasted  three,  four  and 
five  months,  for  it  began  in  the  first  month.  In  three  cases  it  disap- 
peared immediately  after  abortion.  Once,  it  lasted  six  weeks  after 
labor  (Eomberg). 

In  three  cases  there  was  premature  labor,  twice  at  the  beginning  of 
the  ninth  month  and  once  in  the  seventh.  The  chorea  had  persisted,  in 
one  case,  nine  months,  in  one  case  five^  and,  in  one,  only  one  month. 
In  three  cases  the  chorea  ceased  abruptly.  Once  (Aran),  the  patient  had 
a  still-birth  and  died  delirious  the  next  day. 

Barnes,  recapitulating  his  fifty-seven  cases,  reaches  the  following  results: 

cases. 


Spontaneous  labors  at  term. 

00 

Abortions  at  three  months, 

7—t. 

'•'  five 

6  \    8 
1) 

'•'  six 

Premature  labors  at  seven  months,     . 

2)    . 

>19 

^'             "       "  eight       " 

If    ^ 

"             "       date  not  given, 

6 

Abortions,  date  not  given, 

9 

Women  dead  before  delivery,     . 

.'             '^'3 

Abortion  induced,      .         .         .         .         . 

1 

Premature  labor,  induced  at  seven  months 

•           1 

Unknown,          ..... 

11 

57 


190 


A    TREATISE  ON    OBSTETEIOS. 


.  in 

1 

case. 

1 

li 

1 

a 

3 

cases. 

1 

case. 

8 

cases. 

2 

a 

2 

a 

2 

a 

^J,  '■' 

12 

a 

i( 

1 

case. 

In  five  cases  of  Hosier,  the  chorea  continued  until  the  end  of  preg- 
nancy; in  three  cases,  from  the  third  to  the  tenth  month,  and  once,  from 
the  fourth  to  the  tenth. 

In  Ingleby's  case,  (the  fifth  of  Hosier,)  the  disease  reached  its  maximum 
in  five  days,  premature  labor  occurred,  and  the  patient  died  twenty-four 
hours  later.     In  some  cases  the  disease  ceased  before  labor. 

On  the  other  hand,  in  the  cases  of  Barnes: 

Eecovery  occurred  rapidly, 
"'  '•'         in  19  days, 

"  .      "  2i  months. 

The  disease  ceased  before  the  end  of  pregnancy, 
''         "  "       after  abortion 

"      labor, 
"         "       ended  in  an  attack  of  rheumatism, 
"         "       continued  during  the  whole  of  pregnancy, 
'  ■'         "       ended  in  mania, 

Death  occurred  seventeen  times  in  the  days  following  delivery,  the  next 
day  or  the  one  following  that.  Twice  mania  occurred  and  once  eclampsia. 
Amon^  the  seventeen  cases,  there  were  only  six  primipar^  against  eleven 
multipara. 

Among  sixty-eight  cases  collected  by  Fehling,  there  were  nineteen 
deaths.  Among  these,  that  of  Senhouse  Kirke  is  one  of  the  most 
curious.  A  patient  attacked  with  chorea  at  fourteen  years  had  two  mis- 
carriages and  one  labor  at  term.  In  a  fourth  pregnancy  she  was  attacked 
with  severe  chorea  four  days  before  her  confinement,  and  died  four  days 
after  labor. 

When  chorea  develops  late,  it  seems  to  be  more  severe  as  well  as  when  it 
occurs  in  a  second  or  third  labor  or  when  it  relapses.  When,  on  the 
other  hand,  it  begins  from  the  third  to  the  fifth  month  or  before,  it 
rarbly  persists  up  to  the  ninth  month.  In  these  cases  there  is  either  abor- 
tion or  premature  labor  and  a  cure  generally  results. 

Chorea  is  more  serious  in  multiparse  than  in  primiparse.  Spiegelberg, 
who  among  sixty-nine  cases  noted  twenty  deaths,  saw  pregnancy  go  to 
full  term  in  only  twenty-nine  cases.  Death  of  the  child,  however,  does 
not  always  precede  the  interruption  of  pregnancy,  even  in  cases  of  abor- 
tion. The  child  is  often  born  alive  and  has  never  been  seen  affected  with 
chorea.     The  disease  has  no  influence  on  the  post-partum  state. 

Hosier  and  Barnes  find  the  causes  of  death  in  the  complications,  not 
in  the  chorea  itself.  Fehling  has  noted  intestinal  ulcerations  and  cardiac 
affections  five  times,  albuminuria  once,  and  cerebral  affections  (mania  and 
eclampsia)  ten  times.  Cerebral  complications  ought  not  to  occasion  sur- 
]3rise,  if  one  accepts  Barnes'  opinion,  which  locates  the  disease  in  the  cor- 
pora striata. 


DISEASES    OF    PREGNANCY.  191 

In  his  remarkable  study  on  chorea,  Germain  See  states  that  it  has  not 
been  positively  shown  that  chorea  is  more  common  with  pregnant  women 
than  in  others,  but  he  considers  gestation  as  more  or  less  favorable  to  the 
development  of  nervous,  choreic  phenomena.  Among  the  fourteen  cases 
which  he  collected,  he  finds  thirteen  primipara^.  The  chorea  began  three 
times  within  the  first  two  months,  seven  times  from  the  third  to  the  fifth, 
three  times  from  the  fifth  to  the  ninth.  But  he  thinks  that  pregnancy 
is  not  the  real  cause,  and  that  it  acts  only  through  the  usual  causes,  the 
production  of  which  it  favors.  In  his  view,  the  chorea  of  pregnancy  de- 
pends on  no  cause  save  choreic  antecedents.  Five  of  his  patients  had  al- 
ready had  chorea  in  their  youth,  and  only  relapsed  during  their  preg- 
nancy. With  the  others  chorea  was  only  secondary  to  rheumatism,  chloro- 
sis, chronic  dysmenorrhoea,  hysteria  or  hydrgemia,  Avhich  so  often  attend 
both  chorea  and  pregnancy.  The  chorea  of  pregnancy  is  more  stubborn 
than  ordinary  chorea,  and  if  it  is  improved  by  labor,  the  cure  is  not  gen- 
erally effected  for  some  days,  or  even  for  more  than  a  month.  Chorea 
does  not  produce  abortion  itself,  nor  does  it  demand  artificial  premature 
delivery. 

Treatment. — This  should  embrace  general  tonic  measures,  narcotics, 
quinine,  bromide  of  potassium,  and  particularly,  chloral.  Spiegelberg,  in 
cases  where  the  chorea  gets  worse  and  resists  all  treatment,  advises  artifi- 
cial premature  labor  and  even  abortion.  He  especially  recommends  early 
interference. 

Diseases  of  the  Vulva  and  of  the  Vagina. 

Prurihis  Vulvae. 

This  disease,  although  not  peculiar  to  pregnant  women,  sometimes  as- 
sumes especial  intensity  with  them.  By  the  term  is  understood  a  severe 
itching  of  the  external  genitals,  which  sometimes  extends  to  the  introitus 
vagina,  and  amounts  to  real  torture.  Generally,  there  is  no  visible  lesion. 
In  other  cases,  the  women  produce  erosions,  superficial  fissures,  and  some- 
times redness  by  scratching  and  thus  augment  their  sufferings.  Hardy 
has  seen  some  superficial  ulcerations  in  these  cases,  from  which  serum 
exudes,  as  in  eczema.  Cazeaux  has  quoted  a  case  in  which  the  itching 
was  such  that  the  woman  was  in  a  state  of  general  irritation  almost  pro- 
ducing convulsions.  In  another  case  the  friction  had  been  so  often  re- 
peated that  it  had  caused  swelling  and  inflammation  of  the  labia  majora 
and  minora,  one  of  which  was  of  twice  its  natural  age.  Although  devoid 
of  gravity,  pruritus  vulv^  gives  so  much  suffering  that  it  claims  active 
treatment,  which  is  often  inefficacious.  Eest,  -alkaline  baths,  separation 
of  the  inflamed  surfaces,  and  lotions  of  vegetable  and  mineral  waters  some- 
times siicceeds,  as  do  solutions  of  borax,  chlorate  of  potassium  and  weak 
carbolized  water.     Meigs  recommends  ablutions  of  the  parts  with  soap 


192  A    TREATISE    ON    OBSTETEICS. 

and  water,  and  then  tlie  application,  thrice  daily,  of  the  following  solu- 
tion: 

5.  Sodii  borat.  .....  3  ij. 

Morph.  snli)hat grs.  iv.  ss. 

Aqua?  rosae  destill.         .         .         ,         .         fl  3  x.  fl  3  ijss. 

We  have  often  successfully  used  either  just  as  hot  water  as  the  pa- 
tient can  endure,  or  tar  water.  In  obstinate  cases,  we  employ  the  follow- 
ing: 

5  Hydrarg.  bichlorid gr.  xxii.  ss. 

Aqua3  destill f  iv  3  vss. 

Amnion  chlorid Q.  s.  ad.  sol. 

Sig.  One  teaspoonful,  in  a  glass  of  hot  water,  as  a  lotion,  three  times  a 
day.  If  the  case  resists,  we  use  the  solution  undiluted,  applying  it  with 
a  brush  morning  and  evening. 

[In  any  case  of  pruritus  vulvae,  a  very  common  cause  must  be  borne  in 
mind,  and  this  is  endocervical  catarrh,  and  the  resulting  erosion  of  the 
external  os.  The  diagnosis  is  readily  made  by  the  finger — patency  of  the 
external  os  and  cervical  canal,  velvety  softness  of  the  external  os,  and  these 
signs  are  confirmed  by  the  examination  through  Sims's  speculum,  which 
reveals  the  eroded  cervix  and  the  gaping  os.  As  for  treatment,  applica- 
tions to  the  canal  and  the  os,  by  means  of  cotton  wrapped  applicators,  of 
a  solution  of  nitrate  of  silver,  30  to  60  grains  to  the  ounce,  are  the  most 
effective,  and  if  made  gently,  will  not  induce  miscarriage.  In  case  of 
vaginitis  a  similar  solution  should  be  swabbed  over  the  entire  vaginal 
mucous  membrane.  The  most  effective  of  all  means  for  the  relief  of  the 
symptom — pruritus — is  painting  the  external  organs, the  skin  of  the  thighs, 
nates,  etc.,  with  a  solution  of  silver  nitrate,  gr,  x — 5  j. — Ed.] 

Dubois  recommended  cauterization  with  nitrate  of  silver,  which  we  have 
never  employed.  We  have  seen  one  case  of  marked  pruritus,  the  patient 
being  a  young  woman,  at  the  beginning  of  her  second  pregnancy,  which 
resisted  all  treatment,  and  ended  at  two  months  and  a  half  by  an  abor- 
tion. During  a  third  pregnancy,  the  pruritus  reappeared  during  the  first 
two  weeks  of  the  second  month,  but  yielded  to  astringent  lotions,  (Goulard's 
extract)  and  to  separation  of  the  surfaces.  .  The  pregnancy  pursued  its 
regular  course  to  full  term. 

Leucorr'lio&a. 

Almost  all  pregnant  women  have  leucorrhoea.  Generally  it  is  mild,  but 
sometimes  is  severe,  being  then  connected  with  granular  vaginitis.  A 
mass  of  granulations  develop  in  the  vagina,  particularly  during  the  latter 
half  of  pregnancy,  forming  a  rough  surface  and  coexisting  with  erosions 
and  with  superficial  ulcerations  of  the  cervix.  In  this  case  the  discharge 
becomes  very  abundant,  yellower  greenish,  and,  producing  painful  inflam- 


DISEASES    OF    PREGNAISTCY.  Ivd 

matioii  and  superficial  ulceration  of  the  external  genitals,  and  of  the  inner 
aspect  of  the  thiglis,  causes  great  suffering.  The  best  means  of  relief 
consists  in  separation  of  the  surfaces  with  bits  of  fine  linen  dipped  in  a 
solution  of  sub-acetate  of  lead,  in  careful  injections,  in  alkaline  baths,  and 
particularly,  in  tampons  of  cotton.  These  tampons  enclose  equal  parts 
of  alum  and  sub-nitrate  of  bismuth,  and  are  tied  by  a  thread,  which  is 
allowed  to  hang  between  the  legs,  and  serves  to  withdraw  the  tampon. 
We  leave  the  tampon  in  place  three  days,  at  the  end  of  which  time  the 
patient  withdraws  it,  takes  an  alkaline  bath,  and  during  her  bath,  injects 
some  of  the  alkaline  water.     A  new  tampon  is  then  inserted,  and  so  on. 


Fig.  8. — ^Vegetations  of  the  Nymphs. — (McClintock.) 

Generally  after  three  or  four  tampons,  notable  relief  ensues,  if  not  a 
complete  cure.  We  have  never  seen  accidents  due  to  the  tampons. 
[Owing  to  the  well-known  property  of  the  tampon,  of  exciting  uterine 
contractions,  we  should  not  care  to  resort  to  it  here.  The  means  above 
described  by  us,  for  the  relief  of  pruritus,  will  answer  for  the  symptom 
leucorrhoea.  — Ed.  ] 


Vegetations. 

These  are  common  in  pregnant  women  (Fig.  8).  These  vegetations, 
for  a  long  time  considered  syphilitic,  are  not  due  to  syphilis  and  are  de- 
veloped by  pregnancy,  as  Thibierge  has  so  well  shown.  Cullerier,  Boys 
de  Loury,  Costilhes  and  Eicord,  noted  the  coincidence  of  pregnancy  and 
vegetations.  They  appear  at  all  stages  of  pregnancy,  in  the  shape  of  tufts. 
Vol.  II.— 13. 


194  A    TREATISE    OIN"    OBSTETRICS, 

pediciilated  at  the  attachment  and  swollen  like  cauliflower.  They  are 
roseate,  pale,  red,  brown  or  livid.  Sometimes  they  are  isolated,  and  some- 
times aggregated  into  large  masses.  We  have  seen  one  case  in  which  they 
were  almost  as  large  as  a  child's  head.  They  have  an  odoriferous  dis- 
charge, and  occasion  sharp  pains  and  pruritus.  Their  favorite  seat  is 
the  mucous  membrane  of  the  vulva,  the  borders  of  the  labia  majora  and 
the  space  between  these  and  the  labia  minora,  which  their  growth  sepa- 
rates, and  through  which  they  protrude  between  the  thighs,  partly  obli- 
terating the  vulva.  They  may  extend  into  the  vagina  and  up  to  the  cer- 
vix, uteri.  Again,  they  may  extend  to  the  furrow  between  the  buttocks, 
to  the  anus  and  the  groin.  Although  they  constitute  a  source  of  great 
annoyance,  they  are  Hot  serious,  and  generally  resist  all  treatment  up  to 
the  time  of  labor,  when  they  wither  and  fall  off.  In  two  cases,  however, 
in  one  of  which  they  were  as  large  as  an  apple,  we  have  seen  them  disap- 
pear during  pregnancy,  OAving  to  separation  of  the  surfaces  and  the  use  of 
compresses,  dipped  in  Labarraque's  solution.  We  consider  more  energetic 
measures  useless, and  strongly  disapprove  of  all  radical  operations  (excision, 
crushing,  etc.). 

Abdominal  and  IlTERiJsrE  Pains. 

Abdominal,  Lumbar,  and  I)iguinal  Pains. 

These  pains,  to  which  Cazeaux  has  particularly  called  attention,  hardly 
appear  before  the  last  months  of  pregnancy.  They  are  generally  circum- 
scribed and  limited  to  the  lower  part  of  the  thorax,  to  the  origins  and 
insertions  of  the  abdominal  muscles  or  the  groins.  The  pains  are  due,  as 
Tarnier  says,  and  as  Beau  had  already  remarked,  to  lumbo-abdominal  neu- 
ralgia, and  we  may  find  the  maximum  point,  as  in  all  neuralgias,  by  fol- 
lowing the  course  of  the  nerves.  They  generally  yield  to  hypodermic 
morphine  injections.  Again,  there  are  cramps  or  severe  pains  in  the 
thighs  and  the  legs.  These  may  be  due  to  compression  of  the  sacral 
plexus  by  the  foetal  head,  but  as  Tyler  Smith  says,  there  are  cases  in 
which  this  explanation  does  not  serve.  They  are  then  attributed  to  irri- 
tation of  the  large  intestine  or  of  the  uterus,  and  are  considered  reflex. 

In  some  cases  the  uterus  itself  is  the  seat  of  pains  which  come  on  at 
variable  intervals,  and  the  nature  of  which  can  not  be  discovered.  ISTow 
continuous,  now  irregularly  intermittent,  they  occur  in  paroxysms  which 
are  excited  by  pressure,  a  cough  or  by  foetal  movements.  They  are  almost 
always  the  manifestation  of  a  uterine  contraction  which  is  appreciable  to 
the  touch.  Finally,  in  some  cases,  the  sensibility  of  the  uterus  is  exag- 
gerated by  incessant,  violent  foetal  movements.  This  sensibility  is  some- 
times so  extreme  that  each  f  cBtal  movement  is  accompanied  by  acute  pains, 
the  repetition  of  which  greatly  exhausts  the  patients. 


DISEASES    OF    PREC4NANCY.  195 


Uterine  Rheumatism. 


Cazeaux  and  Gauthier  have  particularly  called  attention  to  this  disease. 
Cazeanx  considers  it  true  rheumatism,  but  Gauthier  regards  it  as  identi- 
cal with  uterine  neuralgia,  which  may  also  occur  aside  from  pregnancy. 
Gestation  produces  modifications,  however,  in  its  course,  Spiegelberg 
and  Braiin  do  not  believe  in  uterine  rheumatism  and  consider  it  as  a  re- 
sult either  of  endometritis  or  of  metritis. 

Si/mptoms. — Among  twenty-nine  cases  collected  by  Gauthier,  eighteen 
commenced  during  pregnancy,  before  labor,  and  eleven  began  during 
parturition.  The  attack  is  never  sudden.  Before  the  appearance  of 
uterine  pain  the  patient  complains  of  pains  and  contractions  in  the  limbs 
and  the  trunk,  of  vertigo,  palpitations  and  of  syncope.  Shortly  after- 
ward, or  at  the  same  time,  a.  continuous,  dull  pain,  of  variable  intensity, 
is  felt  in  the  sacrum,  the  hypogastrium  and  the  lateral  abdominal  regions. 
This  pain  is  exaggerated  by  movements  of  the  mother  or  of  the  foetus. 
At  the  end  of  a  few  hours  or  days,  the  pain  becomes  suddenly  violent, 
sharp,  lancinating,  and  lasts  from  a  few  s(>conds  to  several  hours,  begin- 
ning at  the  uterus,  radiating  into  the  lower  limbs,  and  extending  to  the 
bladder  and  rectum.  On  applying  the  hand  to  the  abdomen,  we  find 
that  its  walls  are  not  the  seat,  and  that  the  pain  is  uterine  and  not  so  limited 
as  in  ordinary  neuralgias.  •  Almost  always  one  of  bhe  surfaces  or  sides  of 
the  uterus  is  the  chief  seat  of  the  pain.  The  pain  is  generally  fixed, 
but  may  be  mobile,  the  fundus  uteri  being  usually  less  affected  than  the 
other  regions.  The  women  experience  a  sensation  of  spasmodic  constric- 
tion, due  to  uterine  contraction,  and  perceived  by  the  patients  and  the 
obstetrician  during  the  earlier  months.  The  uterus,  in  fact,  grows  hard. 
Sometimes  it  is  smooth  and  sometimes  nodular,  from  partial  contractions. 
When  the  organ  is  large,  we  can  appreciate  these  changes  in  form,  which 
may,  in  certain  cases,  produce  an  annular  transverse  constriction.  The 
latter  may  be  partial,  and  involve  different  parts  of  the  uterus,  including 
the  cervix,  and  may  occasion,  according  to  the  case,  either  rigidity  or 
rapid  dilatation  of  the  cervix. 

Gauthier  admits  two  forms,  one  acute,  febrile,  and  one  chronic,  apyretic 
form.  The  former  may  succeed  the  latter  or  may  present  momentary 
acute  exacerbations.  Uterine  rheumatism  occurs  most  frequently  at  term 
and  during  labor,  at  which  time  it  may  become  the  cause  of  dystocia.  It 
may  be  developed  after  labor,  either  immediately  or  after  a  few  hours. 
It  then  causes  spasmodic  uterine  contractions,  which  lead  to  retention 
of  the  placenta.  Finally,  it  may  occur  later  yet,  after  fifteen  days,  as  in 
a  case  of  JSTeucourt. 

The  usual  complications  are  neuralgic  or  rheumatic  pains  in  certain 
viscera,  in  the  muscles  or  in  different  nerves,  particularly  the  vesical  and 
rectal  nerves.     Lurotli  has  seen  a  case  of  rheumatic  meningitis,   and 


196  A    TEEATISE    ON    OBSTETRICS. 

finally,  there  may  be  muscular  pains  in  the  face,  the  neck,  the  arm,  the 
shoulder,  the  thoracic  walls  and  in  the  lower  limbs. 

Very  prone  to  relapse,  this  affection  may  recur  several  times,  during  or 
after  pregnancy.  The  intervals  vary  from  two  or  three  days  to  several . 
weeks.  An  individual  attack  varies  from  a  quarter  of  an  hour  to  twelve 
days,  at  the  longest,  but  in  general,  it  does  not  exceed  twenty-four  or  forty- 
eight  hours.  The  disease  may  reappear  in  successive  pregnancies.  The 
disease  may  end  in  recovery,  which  is  the  rule,  in  a  chronic  condition,  in 
metritis  and  in  eclampsia. 

1.  Influence  ufjon  Pregiiaiicy. — When  the  attacks  have  lasted  a  certain 
time,  and  have  been  violent,  they  are  followed  by  uterine  contractions, 
and  may  thus  provoke  labor.  But  it  is  not  always  so,  and  Wigand  quotes 
a  case  where  the  cervix  dilated,  and  the  bag  of  waters  formed;  when 
everything  was  arrested,  labor  ceased,  the  os  closed,  the  cervix  regained 
its  former  length,  and  pregnancy  went  on  its  course.  Sometimes  the 
pains  simulate  labor  without  inducing  it,  and  they  may  occasion  faulty 
presentations. 

3.  Influence  upon  Labor. — Uterine  rheumatism  impedes  labor,  and 
sometimes  even  renders  the  spontaneous  expulsion  of  the  foetus  impossi- 
ble by  interfering  with  the  pains,  by  producing  spasm  of  the  cervix,  and 
by  preventing  the  woman  from  making  voluntary  expulsive  movements. 

3.  Influence  upon  the  Puerperal  Functions.' — By  causing  tetanic  uter- 
ine contractions,  it  may  produce  dystocia  or  may  occasion  hemorrhage  by 
inducing  uterine  atony,  which  may  be  followed  by  metritis  or  by  perime- 
tritis. 

Causes. — These  are  difficult  of  detection.  The  disease  may  appear 
under  all  circumstances  and  at  any  stage  of  pregnancy.  G-authier  saw 
it  begin  in  twenty-nine  cases,  as  follows: 

In  the  2d  month,  1  ^ 
"    "  3d       ''       3 
((    <(  A\\.     "       1  (     ^^  ^^®  ^^'^^  ^^^  months,  6  times. 

"  "  5th  ''       IJ 

"  "  6th  "       %\ 

"  *•   7th  "  4  f     In  the  last  four  months  (twelve 

"  "  8th  "  5  f     occurring  in  the  last  month),  23  times. 

''  "  9th  ^^  I2J 

Meissner  regards  rheumatism  as  a  neurosis  of  uterine  sensibility  and 
motility,  caused  by  peripheral  irritation,  and  particularly  by  cold. 

The  predisposition  increases  as  the  full  term  approaches,  and  is  nota- 
bly augmented  near  the  time  of  labor. 

Prognosis. — Although  not  fatal  to  the  woman,  uterine  rheumatism  is 
still  serious  because  it  may  occasion  abortion  or  premature  labor,  or  by 
retarding  and  complicating  labor  it  makes  the  condition  of  both  mother 
and  child  much  less  favorable.     It  is  particularly  disagreeable  when  de- 


DISEASES    OF   PREGNANCY. 


197 


velopecl  at  the  end  of  pregnancy,  because  of  its  tendency  to  recur  several 
times  before  confinement,  even  when  it  does  not  interrupt  pregnancy. 
In  these  cases  it  almost  always  recurs  during  parturition,  which  it  renders 
long  and  difficult. 

Treatment. — This  consists,  during  pregnancy,  in  venesection,  revulsion 
through  the  intestine  and  in  narcotics,  either  internally,  subcutaneous- 
ly,  or  by  enema.     Chloral  has  proved  very  useful  in  these  cases. 

During  Labor. — We  give  the  preference  to  chloral  and  to  chloroform, 
and  we  hasten  the  termination  of  labor  as  much  as  is  compatible  with  the 
mother's  safety. 

After  Labor. — We  prefer  to  use  laudanum  enemata,  twenty  drops  in 
three  ounces  of  water,  to  be  repeated  two  or  three  times  in  twenty-four 
hours.  In  a  stubborn  case,  we  pushed  the  dose  to  one  hundred  drops  in 
twenty-four  hours,  without  causing  any  results,  aside  from  marked  relief, 
except  head-ache  and  somnolency. 

Displacements  and  Deviations  of  the  Uterus. 

Prolapse  of  the  Uterus. 

Prolapse  of  the  uterus,  during  pregnancy,  may  be  either  incomplete  or 
complete.     In  the  latter  case  the  whole  organ  escapes  from  the  genital 


a 


Fig.  9.  Fig.  10. 

Fig.  9.— Complete  Prolap.se  of  Uterus,  the  resxjlt  of  Elongation  of  the  Cervix.— a, 
Urinary  meatus.    6,  Invaginated  ant.  vag.  wall,    c,  Ext.  os.    d,  Vag.  portion  of  cervix. 

Fig.  10. — Complete  Prolapse  of  Uterus,  without  Cystocele.  Rectocele  and  Enterocele.— 
a,  Urinary  meatus.    6,  Uterus,    c,  Rectocele. 

canal,  and  hangs  between  the  thighs.  (Figs.  9  and  10),  This  form  is 
very  rare.  These  displacements  may  develop  slowly  or  suddenly,  in  cases 
where  prolapse  pre-existed  or  not.  Spiegelberg  believes  that  a  certain 
9,mount  of  prolapse  always  precedes  the  pregnant  condition. 

The  accidents,  according  to  Cazeaux,  which  result  from  this  displace- 
ment, vary  in  intensity,  according  to  the  degree  of  displacement  and  the 


198  A   TREATISE    OJST   OBSTETRICS. 

period  of  pregnancy  at  which  it  occurs.  When  the  pelvis  is  too  roomy, 
but  the  straits  of  normal  size,  the  uterus  remains  in  the  true  pelvis  much 
longer  than  under  other  circumstances.  The  uterus  then  presses  upon 
the  rectum  and  the  bladder,  irritating  them.  The  woman  experiences  a 
sensation  of  weight  at  the  anus  and  of  painful  traction  at  the  groins,  the 
loins  and  the  navel.  There  is  a  fetid  discharge.  The  patient  can  neither 
stand  up  nor  walk  easily,  and  she  falls,  gradually,  into  a  state  of  marasmus. 
If  pregnancy  has  just  begun  and  the  uterus  is  either  very  large  or  has  de- 
scended to  a  greater  extent,  the  accidents  are  more  deplorable  still.  Com- 
plete retention  of  urine  and  obstinate  constipation  may  result.  The  irri- 
tation resulting  in  the  uterus  itself  may  lead  to  abortion.  These  compli- 
cations generally  cease  when,  at  the  fifth  month,  the  uterus  is  unable  to 
develop  farther  within  the  pelvis  and  rises  above  the  superior  strait. 

Hliter  who,  in  1860,  collected  all  the  cases  up  to  his  time,  divides 
them  as  follows: 

1.  The  gravid  uterus  being  prolapsed,  reduces  itself  during  the  first 
months,  and  pregnancy  and  labor  follow  their  usual  course;  5  cases. 

2.  The  prolapse  is  not  spontaneously  reduced.  Its  artificial  reduction 
and  support  must  be  undertaken;  8  cases. 

3.  Eeduction  cannot  take  place  on  account  of  incarceration;  3  cases. 

4.  The  prolapse  causes  labor  before  term;  7  cases. 

5.  Prolapse  occurs  in  the  second  half  of  pregnancy,  and  persists  up  to 
term  and  during  labor;  3  cases. 

6.  Prolapse  takes  place  shortly  before,  or  durmg  ^abor,  at  term.  In 
this  case,  prolapse  may  not  have  existed  before  labor,  or,  having  existed 
before,  was  spontaneously  reduced  during  the  first  months  of  pregnancy, 
or  the  prolapse  was  reduced  and  the  uterus  maintained  by  a  pessary;  16 
cases. 

7.  Prolapse  occurs  during  labor  and  delivery;  15  cases. 

8.  Prolapse  existed  before  pregnancy,  but  only  became  pronounced 
during  labor;  16  cases,  making  a  total  of  73  cases. 

Causes. — It  was  impossible  for  Hiiter  to  divide  the  cases  into  those  of 
complete  and  incomplete  prolapse.  Among  sixty-nine  cases,  there  were 
ten  primiparse,  twenty-seven  multiparee  and  thirty-two  unknown.  In 
thirty-five  patients,  seven  of  them  being  primiparse,  prolapse  existed 
before  pregnancy.  In  thirty-four  patients,  three  being  primiparae,  this 
was  not  noted. 

Hiiter  concludes  that  antecedent  prolapse  is  the  cause  of  prolapse  dur- 
ing pregnancy,  since  it  exists  in  one  half  of  the  cases.  Hiiter  states:  1. 
That  in  sixteen  cases,  the  uterus  prolapsed  before  pregnancy,  remained 
prolapsed  during  this  pregnancy.  2.  That,  in  five  cases,  prolapse  which 
did  not  exist  during  a  certain  period  of  pregnancy,  resulted  from  efforts 
and  traumatism. 

Among  twenty-four   women    in  labor,    eleven  of    them  being    primi- 


DISEASES    OF    PREGNAKCY.  199 

parte,  the  prolapse  which  existed  before  pregnancy  recurred  with  it. 
Among  fourteen  women  in  labor,  three  of  whom  were  primiparte,  the 
prolapse  occurred  for  the  first  time  during  labor,  owing  solely  to  the 
uterine  contractions;  in  eight  cases  it  already  existed  before  pregnancy. 
In  two  primiparas  it  was  due  to  traction  with  the  forceps.  One  had 
already  had  a  prolapse  before  pregnancy,  the  other  not. 

In  two  cases,  the  pelvis  was  extremely  large,  and  in  one  case  the  vulva. 

The  most  active  causes,  however,  are  the  efforts  of  labor. 

To  recapitulate  the  causes:  Multiparous  state,  pre-existence  of  pro- 
lapse, efforts,  traumatism,  uterine  contractions,  the  forceps,  justo-major 
pelvis,  large  vulva,  efforts  during  labor. 

Fritsch  attributes  a  powerful  influence  to  arrest  of  uterine  involution, 
after  first  labors.  The  enlarged  uterus  will  have  a  better  chance  to  de- 
scend if  the  perineum  has  been  lacerated.  Labor  has  a  particularly  pre- 
disposing influence  when  the  membranes  are  ruptured  before  complete 
dilatation  of  the  cervix.  The  foetus  pushes  forward  the  rigid  cervix, 
which  may  thus  be  protruded  through  the  vulva,  dragging  the  vagina 
after  it.  If  uterine  involution  is  incompletely  accomplished,  the  uterus 
will  remain  low  down,  for  the  over-stretched  peritoneal  ligaments  will  no 
longer  sustain  this  organ. 

Course. — Ordinarily,  pregnancy  proceeds  undisturbed  to  full  term.  In 
only  ten  cases  did  premature  labor  occur.  In  two  cases  death  resulted 
from  incarceration  of  the  uterus. 

In  thirty-four  cases  the  child  presented  by  the  vertex;  in  nine  by  the 
pelvic  extremity. 

In  five  cases  the  feet  were  brought  down  by  version.     (Fig.  11). 

In  only  six  cases  was  labor  normal,  and  four  of  these  labors  were  pre- 
mature. 

In  seventeen  cases  the  presentation  was  not  noted. 

In  two  cases  there  were  twins,  which  presented,  in  one  instance,  by  the 
breech. 

In  all  the  other  cases,  save  the  six  referred  to  above,  intervention  was 
necessary  either  because  of  tedious  labor,  due  to  slow  dilatation  in  spite 
of  good  pains,  or  to  inefficient  action  of  the  abdominal  muscles,  or  because 
of  serious  complications  (rupture  in  three  cases,  from  excessively  strong 
contractions  and  gangrene  of  a  part  of  the  prolapsed  uterus). 

Prognosis. — This  is  favorable,  for  the  prolapse  is  almost  always  sponta- 
neously reduced  in  the  first  months,  and  pregnancy  and  labor  generally 
take  their  normal  course.  The  prognosis  is  even  good  for  the  con- 
tinuance of  pregnancy,  when  artificial  reduction  and  the  introduction  of 
a  pessary  are  necessary  (nine  cases).  But  the  outlook  is  much  more 
serious  when  incarceration  occurs  (two  deaths).  Among  the  seven  cases 
of  premature  labor  or  of  abortion,  there  was  one  death. 


200 


A    TREATISE    OJST    OBSTETRICS. 


For  the  child,  the  prognosis  is  bad  iu  proportion  to  the  rapidity  of 
labor. 

Among  fifty-six  women  at  term,  six  died,  one  in  labor,  and  five  during 
the  puerperium. 

Among  the  fifty-six  children,  nineteen  were  born  alive,  fourteen  dead, 
and  the  fate  of  twenty-four  was  not  noted. 

Treatment.— This  consists  in  favoring  spontaneous  reduction  by  ap- 
propriate postures  on  the  patient's  part.  If  it  does  not  occur,  the 
Germans,  more  audacious  than  Cazeaux,  advise  artificial  reduction  as 
early  as  possible,  and  support  by  means  of  a  pessary.  Hiiter,  going  still 
further,  recommends  these  measures  even  at  eight  months. 


Fig.  11. — Complete  Prolapse  op  Uterus  at  Term. — Pi-esentation  of  a  foot:  (multipara,  aged 
thirty-eight.)  a,  Meatus  urinarious.  b,  Prolapsed  uterus,  c,  Cervix  at  term,  through  which  afoot 
projects. 

If  reduction  fails,  the  uterus  is  to  be  sustained  by  a  suspensory  bandage 
and  removed  from  all  causes  of  irritation. 

If  symptoms  of  incarceration  are  developed,  artificial  abortion  is  justifi- 
able. When  labor  is  protracted,  artificial  delivery  is  to  be  carefully  per- 
formed by  the  forceps  or  version.     The  uterus  is  subsequently  reduced. 


Uterine  Deviations. 

The  uterine  deviations  are  lateral,  the  obliquities  of  the  older  writers; 
anterior,  or  anteversions;  posterior,  or  retroversions.  That  is  to  say, 
there  are  deviations  ero  masse  or  partial  deviations;  anteflexions,  retro- 
flexions, latero-flexions.     All  are  not  of  equal  importance. 


DISEASES    OF    PREGNANCY.  201 

1.    Uterine  Obliquities;  Lateral  Deviations. 

The  older  writers  attached  great  importance  to  these,  but  in  reality  they 
are  not  well-marked  and  never  cause  serious  complications.  They  only 
affect  labor,  and  this  by  retarding  cervical  dilatation.  We  shall  return  to 
them  in  the  chapter  on  Dystocia. 

3.  Partial  Deviations;  Flexions. 

Conception  is,  according  to  Hoist,  not  so  rare  as  it  is  thought  to  be  in 
cases  of  uterine  flexion.  He  collected  eight  cases  in  point,  and  it  must 
not  be  supposed,  because  conception  occurs  while  the  flexion  is  being 
treated,  that  the  flexion  is  cured.  If  flexion  often  induces  sterility,  it  is 
because  the  flexion  is  generally  complicated  by  chronic  inflammations  of 
the  mucous  membrane  and  of  the  parenchyma;  by  cervical  catarrh,  by 
erosions,  by  granulations  and  by  amenorrhoea.  But  these  are  not  positive 
obstacles.  When  the  flexed  uterus  is  healthy,  the  cause  of  sterility 
resides  in  the  faulty  position  of  the  cervical  orifice, which  is  directed  either 
backward  or  forward.  It  is,  therefore,  no  longer  in  contact  with  the  end 
of  the  urethra  at  the  moment  of  ejaculation,  and,  moreover,  the  bend  in 
the  uterus  prevents  the  penetration  of  the  spermatic  fluid.  Hoist  justly 
objects  to  this  latter  cause,  as  there  should,  otherwise,  always  be  retention 
of  the  menstrual  blood,  which  does  not  occur.  That  which  renders  con- 
ception possible  is  the  disappearance  of  complications,  the  ability  of  the 
cervix  to  retain  its  normal  position  and  the  preservation  of  the  uterine 
cavity. 

[The  shape  of  the  cervix  is  more  likely  to  impede  conception  than  the 
mere  fact  of  flexion.  The  conical  shape,  usually  accompanied  by  pin- 
hole OS,  is  a  frequent  accompaniment  of  sterility.  To  refer  only  to  the 
data  of  the  late  James  Marion  Sims,  he  found  this  conical  shape  in  nearly 
85  per  cent,  of  the  cases  of  sterility  which  he  investigated. — Ed.] 

When  conception  has  taken  place,  pregnancy  has  little  chance  of  reach- 
ing an  end,  as  abortion  very  frequently  occurs. 

Hiiter  reverts  to  the  frequency  of  abortions  in  uterine  flexions,  and 
considers  the  larger  part  of  those  abortions,  which  take  place  in  the  early 
months  of  pregnancy,  and  the  cause  of  which  escapes  observation,  to  be 
occasioned  by  these  flexions.  He  thus  explains  the  occasionally  frequent 
recurrence  of  abortion,  without  known  cause,  in  the  case  of  certain 
women.  He  cites  three  cases  in  point,  the  first  one  being  extremely  in- 
teresting: 

First  abortion,  tenth  week  of  pregnancy. 
Second    "  "  "     ''        *" 

Third       "          seventh"     " 
Fourth    "         tenth      "     " 

All  these  abortions  occurred  without  appreciable  cause.     Anteflexion 


202  A   TREATISE    ON    OBSTETRICS. 

was  found  to  exist  when  pregnancy  did  not.  In  a  fifth  pregnancy  there 
was  anteflexion  and  anteversion.  The  uterus  was  replaced  at  times  cor- 
responding to  the  second  and  third  menstruation.  The  pregnancy  was 
not  interrupted.  Labor  occurred  at  term  and  the  post-partum  period 
was  normal.  [We  believe  it  very  doubtful  if  abortion  was  ever  produced 
by  simple  flexion.  There  are  so  many,  often  latent,  causes  of  miscarriage, 
that  we  are  scarcely  warranted  in  laying  this  to  flexion.  We  do  not  refer 
here,  of  course,  to  cases  where  version  accompanies  flexion. — Ed.] 

He  concludes  from  his  observations,  that  this  supposed  predisposition 
to  abortion  does  not,  in  reality,  exist,  and  that  abortion  is  always  occa- 
sioned by  a  cause  which  may  momentarily  escape  observation  because  it 
is  not  always  easy  to  discover  at  once. 

Flexions  disappear  during  abortions,  so  that  the  diagnosis  of  these  cases 
is  only  possible  before  the  beginning  of  abortion  or  some  time  after  its 
termination. 

It  is  not  uterine  flexion  itself  which  produces  abortions,  but  the  ante-  or 
retro-versions  which  accompany  them. 

Treatment  must,  therefore,  be  directed  against  anteversions  and  retro- 
versions. 

Philips  adopts,  without  reserve,  the  opinion  of  Hiiter  as  regards  the 
frequent  recurrence  of  abortions. 

3.  Anteversio?i. 

Uterine  anteversion  is  merely  an  exaggeration  of  a  normal  state,  and 
hecomes  really  pathological  only  when  it  exceeds  a  certain  limit  or  when 
it  occurs  in  the  true  pelvis,  i.e.,  in  the  first  months  of  pregnancy.  Dur- 
ing the  last  months,  it  constitutes  what  is  called  pendulous  abdomen,  and 
it  is  well  known  under  what  circumstances  this  is  produced.  The  mul- 
tiparous  state,  relaxation  of  the  abdominal  walls,  eventration  and  rachitis 
are  causes.  It  is  not  rare,  in  these  cases,  to  find  women  whose  abdomens 
rest,  as  it  were,  upon  the  thighs,  the  fundus  uteri  forming  the  lowest 
part  of  the  abdomen,  the  cervix  being  carried  upward  and  backward. 
The  patients,  of  course,  suffer  from  renal  pains  and  dysuria.  The  fcetus  is 
not  within  reach  and  delivery  is  difficult. 

But  anteversion  may  occur  during  the  first  months  of  pregnancy  (Fig. 
14, )  before  the  uterus  has  risen  from  the  true  pelvis,  and  it  is  in  these 
cases  that  it  really  becomes  pathological. 

Hiiter  has  examined  it,  particularly  from  this  point  of  view. 

Eecalling  the  observations  of  BaudelocqUe,  Chopart,  Ashwell,  Boivin, 
Hachmann,  Welcke,  Godefroy  and  adding  two  cases  of  his  own,  he  distin- 
_guishes  three  degrees  of  anteversion. 

First  Degree. — This  is  about  the  normal  state.  The  longitudinal  uter- 
ine axis  forms  a  very  acute  angle  with  the  pelvic  axis. 


DISEASES    OF    PREGNANCY. 


203 


Second  Degree. — The  fundus  approaches  the  synipliysis  but  does  not 
reach  it.     The  angle  formed  by  the  two  axes  is  less  acute. 

Third  Degree. — The  fundus  reaches  the  symphysis.  The  angle  is  al- 
most a  right  angle.  The  portio  vaginalis  of  the  cervix  is  carried  more  or 
less  backward  toward  the  posterior  pelvic  wall.     It  is  very  rare  to  see  the 


Fig.  12. — Anteversion  op  the  Uterus.  (After  Legendre.)—A,  Bladder.  B,  Rectum.  C,  Body  of 
uterus.  D,  Vaginal  orifice.  E,  Symphisis  pubis.  F,  Anus.  G,  Sacrum.  H,  Left  labium  minus. 
/,  Clitoris,  root  of  corpus  cavernosum,  cut  across.  J,  Left  labium  majus.  K,  Meatus  urinarius. 
i,  Pyramidalis  muscle.  M,  Rectus  abdominis.  N,  Anterior  peritoneal  cul-de-sac.  0,Vesico-uterine 
cul-de-sac.  P,  Retro-uterine  cul-de-sac.  B,  Levator  ani.  S,  External  sphincter.  T,  Internal  sphinc- 
ter. U,  Anterior  lip  of  cervix.  F,  Posterior  lip.  X,  Coccyx.  F,  Venous  plexus  of  Santorini.  Z, 
Venous  plexus  of  vagina,  a,  Muscular  tunic  of  the  bladder  and  urethra.  6,  Muscles  of  rectum,  d, 
Fibro-cellular  vaginal  tunic,  e,  Fiftk  lumbar  vertebra.  /,  Uterine  cavity,  g.  Section  of  uterine 
veins,    h,  Rachidian  canal. 

cervix  remaining  in  front,  except  in  the  case  where  there  is,  simultane- 
ously, anteversion  and  anteflexion.  It  is,  usually,  during  labor  that  this 
result  is  brought  about  by  the  influence  of  the  pains.  At  the  same  time 
that  it  inclines  forward,  the  uterus  undergoes  a  torsion  upon  its  transverse 
axis.  As  a  result,  the  anterior  vaginal  wall  is  distended  by  the  uterus 
and  pushed  forward.     The  posterior  v/all  does  not  look  directly  toward 


204 


A   TREATISE    OlS"    OBSTETRICS. 


the  rectum  but  becomes  oblique  and  almost  horizontal.  The  uterus  com- 
presses both  the  rectum  and  the  bladder,  causing  difficulty  in  micturition, 
in  defecation  and  in  the  introduction  of  the  sound. 

Causes, — Lohmeier,  Kiwisch  and  Scanzoni  do  not  believe  in  primary 
anteversion.  Hiiter  shows  that,  the  uterus  being  already  normally  ante- 
verted,  if  the  pelvis  is  wide  and  larger  than  usual,  and  if  the  pelvic  axis  is 
more  inclined,  the  posterior  surface  of  the  uterus  has  a  greater  and  greater 
tendency  to  become  superior.  It  follows  that  the  pressure  exerted  by  the 
intestines  becomes  more  considerable  and  thus  tends  to  produce  and  to 


Fig.  13.— Anteversion  of  the  Uterus.  (After  Legendre^—A^  Bladder.  B,  Rectum.  C,  Body  of 
uterus.  D,  Vaginal  orifice.  E,  Symphysis  pubis.  F,  Anus.  6r,  Sacrum.  H,  Left  labium  minus, 
/,  Clitoris,  root  of  corpus  cavernosum,  cut  across.  J,  Left  labium  majus.  K,  Meatus  urinarius. 
i,  Pyramidalis  muscle.  3f,  Rectus  abdominis.  iV,  Anterior  peritoneal  cul-de-sac.  O,  Vesico-uterine 
cul-de-sac.  P,  Retro-uterine  cul-de-sac.  R,  Levator  ani.  8,  External  sphincter.  T.  Internal  sphinc- 
ter. U,  Anterior  lip  of  cervix.  F,  Posterior  lip.  X,  Coccyx.  Y,  Venous  plexus  of  Santorini.  Z, 
Venous  plexus  of  vagina,  a,  Muscular  tunic  of  bladder  and  urethra,  b.  Muscles  of  rectum,  d, 
Fibro-cellular  vaginal  tunic,  e,  Fifth  lumbar  vertebra.  /,  Uterine  cavity,  g,  Section  of  uterine 
veins,    h,  Rachidian  canal. 

increase  the  anteversion.  Ovarian  or  other  tumois^  ascites  and  peritoneal 
adhesions  act  in  the  same  way.  If  there  be  superadded  to  this  a  relaxa- 
tion of  the  vaginal  wall  and  of  the  uterine  ligaments,  particularly  of  the 
round  ligaments,  and,  finally,  vaginal  cystocele,  it  is  -plam  how  the  accu- 


DISEASES    OF    PKEGISTAlSrCY. 


205 


mulation  of  urine  in  the  bladder  will  produce  ante- version.  It  may  be  de- 
veloped slowly  or  suddenly  and  be  particularly  favored  by  a  sudden  and 
exaggerated  pressure  of  the  bowels,  by  sudden  contractions  of  the  abdom- 
inal muscles  and  by  sudden  depression  of  the  diaphragm.  When  the  an- 
teversion  has  reached  a  certain  degree  it  may  thus  pass  to  a  more  advanced 
stage  from  the  slightest  cause. 

Signs.- — So  long  as  it  is  moderate,  ante  version  passes  unnoticed,  but, 
when  it  is  exaggerated,  there  soon  follow  dysuria,  frequent  micturition, 
constipation,  tenesmus,  and  pains  in  the  loins  and  sacrum,  which  attain 
their  maximum  in  the  third  degree  of  anteversion.  The  lumbar  and 
sacral  pains  are  constant,  and  are  due  to  traction  upon,  or,  according  to 
Hiiter,  even  to  laceration  of  the  retro-uterine  folds.  Constipation  be- 
comes complete,  and  there  is  a  constant  desire  to  urinate,  although  the 


Fig.  14.— Vertical  Section  of  the  Pelvis,  representing  Ajjteversion  of  the  Uterus  in  the 
EARLY  stages  OP  PREGNANCY.— a,  Right  pubis.  6,  The  sacrum,  c,  The  bladder,  d,  The  urethra. 
ec,  The  rectum.  /,  Section  of  the  tube  and  of  the  left  broad  ligament,  g,  Body  of  the  uterus.  7i, 
Lateral  portion  of  the  uterus,  not  covered  by  peritoneum,  i,  Os  tincce.  fc,  The  vagina.  {Boivin  & 
Duges.) 

bladder  contains  very  little  urine.  The  patients  feel  a  sense  of  weight  in 
the  pelvis,  as  if  there  were  something  to  be  expelled  by  the  anus.  The 
abdominal  walls  and  the  diaphragm  accordingly  contract,  and,  tending  to 
further  depress  the  fundus  uteri,  increase  the  trouble.  Then  follow  fever, 
nausea,  emesis  and  spasms. 

Authors  do  not  agree  about  the  condition  of  the  bladder.  While  God- 
efroy  and  Hiiter  have  always  found  the  bladder  empty,  Kyll,  Hachmann, 
Boivin  and  Duges  admit  that  urine  may  accumulate  in  that  part  of  the 
bladder  which  is  above  the  point  compressed  by  the  uterus. 

Course  and  Prognosis. — Most  cases   pass  unobserved,  and   the  grave 


206 


A    TREATISE    ON   OBSTETRICS. 


symptoms  disappear  wlien  the  uterus  rises  out  of  the  pelvis,  between  three 
and  a  half  and  I'our  months.  If  it  remains  incarcerated  in  the  true  pelvis 
serious  symptoms  may  appear,  and  first  pregnancy  and  later  the  life  of 
the  mother  may  be  endangered.  But  this  is  not  absolute,  for  the  incar- 
ceration is  never  complete  as  in  retroversion. 

When  anteversion  occurs  suddenly,  pregnancy  is  less  secure,  but  all  de- 
pends, in  this  case,  on  the  time  which  elapses  before  the  reduction  of  the 
uterus.  Generally,  all  the  grave  symptoms  disappear  when  the  uterus 
is  once  replaced,  and  pregnancy  pursues  its  regular  course. 

Treatment. — This  consists,  first  and  foremost,  in  reduction  of  the  dis- 
placed organ.  Complications  must  then  be  met  by  appropriate  means, 
but  especial  care  must  be  exercised  in  providing  for  evacuation  of  the 
bladder  and  of  the  rectum. 


Fig.  15.— Retroversion  of  the  Uterus,  early  in  Pregnancy.— a,  Right  pubis.  6,  Os  tincce.  c, 
Canal  of  the  urethra,  d,  Vagina,  e,  Body  of  the  uterus.  /,  The  bladder  at  Its  maximum  develop- 
ment. 3,  The  rectum,  ft,,  The  sacro-vertebral  angle,  i,  Section  of  the  tube  and  of  the  left  broad 
ligament.    {Boivin  &  Duges.) 

[  A  so-called  supra-pubic  pad  abdominal  supporter,  will  ordinarily  cor- 
rect the  anteversion  after  the  uterus  has  risen  above  the  brim.  Before 
this  period,  the  symptoms  are  rather  due  to  downward  sagging  of  the 
uterus,  and  traction,  in  consequence,  on  the  neck  of  the  bladder.  In  this 
case,  the  open  cup-pessary  of  Thomas  may  be  tried,  often  with  relief  to 
the  main  symptom — vesical  tenesmus. — Ed.] 


4.  Retroversion. 

Uterine  retroversion  consists  in  the  complete  displacement  of  the  organ 
in  the  pelvic  cavity,  so  that  the  fundus  is  contained  in  the  hollow  of  the 


DISEASES    OF    PREGNANCY. 


207 


sacrum  while  the  cervix  is  carried  forward  beneath  the  symphysis  pubis 
(Salmon)  (Fig.  15). 

We  thus  at  once  eliminate  what  the  Germans  call  a  partial  retroversion^, 
and  what  Depaul  styles  a  sacriform  dilatation.  This  we  will  study  in  the 
following  chapter. 

Frequency. — "Although  one  cannot  say  that  retroversion  is  a  very  rare 
accident,  the  cases  are  still  so  few  that  it  is  difficult  to  collect  more  than 
forty  or  fifty  examples  from  all  medical  literature.  For  my  part,  during 
a  practice  of  thirty  years,  which  has  afforded  me  the  opportunity  of  ob- 
serving nearly  everything  unusual  in  obstetrics,  I  have  only  seen  eight  or 
ten  cases  of  retroversion  during  pregnancy.  P.  Dubois  had  hardly  seen 
more,  and  his  father  had  never  seen  a  case  in  his  long  practice."  These 
are  the  words  of  Depaul. 


Fig.  16.— Retroversion   of   the  Uterus. 
Bladder. 


(After   SchuUze).—!,  Intestine.      U,   IJtenis.     V, 


Since  Baudelocque,  two  kinds  of  uterine  retroversion  are  described  and 
based  upon  their  respective  causes. 

The  first  form  is  slow  and  progressive,  the  second  form  sudden  and 
accidental. 

Causes. — 1.  Gradual  Retroversion.  All  authors  admit  that  the  uterus 
is  lowered  in  the  first  months,  and  that  it  is  originally  developed  at  the 
expense  of  its  fundus  and  of  its  posterior  wall. 

But,  while  Denman,  Merriman,  Desormeaux,  Paul  Dubois,  Danyau 
and  Jacquemier  consider  the  retention  of  urine  to  be  the  occasional  cause 
of  retroversion,  William  Hunter,  Burns,  Moreau  and  Cazeaux  think  that 
the  retention  of  urine  is  the  effect  and  not  the  cause  of  retroversion, which 


208  A    TREATISE    OjST    OBSTETRICS. 

is,  itself,  produced  Ly  another  mechanism.  Depanl,  in  1853,  resolutely 
took  liis  stand  Avitli  the  former  class  of  authors.  He  held  that  retention 
is  an  occasional  cause  of  retrover^on  (Fig.  16),  and  he  is  the  more  justi- 
fied in  holding  this  opinion  as  he  has  seen  the  bladder  distended  by  an 
enormous  quantity  of  urine  in  cases  of  retroversion  not  occurring  during 
pregnancy.  Jacquemier  had  already  stated,  to  explain  these  facts,  that, 
when  the  distension  of  the  bladder  by  the  urine  is  long  continued,  the 
organ  can  contain  a  large  quantity  of  the  liquid  without  being  over-dis- 
tended. Then,  its  walls  being  pai'tially  dilated,  and  particularly  behind, 
it  forms  a  large  sac  Avhich  displaces  the  fundus  uteri  towards  the  hollow 
of  the  sacrum,  while  the  cervix  is  retained  in  its  ordinary  position.  De- 
panl adds  that,  in  this  case,  the  bladder,  in  subsequently  rising  into  the 
abdominal  cavity,  draws  the  cervix  upward  and  this  increases  the  dis- 
placement already  begun.  This  is  the  explanation  of  Boivin  and  Duges, 
of  Desormeaux  and  of  Dubois,  and  we  adopt  it  in  its  entirety. 

The  accumulation  of  feeces  in  the  intestine,  above  the  iliac  fossa, 
has  been  assumed  as  a  cause.  Desormeaux,  Dubois  and  Depaul,  although 
accepting  this  cause,  think  that  it  must  be  preceded  by  a  certain  degree 
of  retroversion. 

Other  assumed  causes  are  curvature  of  the  sacrum,  justo-major  pelvis, 
insertion  of  the  placenta  at  the  fundus  or  on  the  posterior  wall  of  the 
uterus,  deformed  pelvis,  uterine  prolapse,  fibroid  uterine  tumor,  ovarian 
tumors,  abnormally  wide  vagina,  adhesions  due  to  old  peritonitis,  the 
multiparous  state,  feebleness  of  constitution,  etc. 

2.  Sudden  and  Accidental  Retroversion. — Besides  the  predisposing  con- 
ditions cited  above,  the  following  are  given  by  different  authors:  efforts, 
blows,  falls,  pressure  on  the  abdomen,  sudden  backward  displacement  of 
the  cervix  in  prolapse,  and  emotions.  Salmon  quotes  two  cases  of 
Eolland  and  Godefroy,  in  which  it  was  due  to  violent  and  unavailing 
efforts  to  urinate. 

Time  of  Appear ance. — Ketro version  is  a  disease  of  the  first  half  of  preg- 
nancy. It  occurs,  generally,  between  the  third  and  the  fourth  month 
(in  nineteen  out  of  Salmon's  twenty-seven  cases).  It  rarely  takes  place 
before  the  third  month  (only  five  cases).  It  may  occur  from  the  fourth 
to  the  fifth  month  (five  cases).  It  may,  very  exceptionally,  occur  after 
the  fifth  month  (three  cases). 

Signs.  — The  authors  of  to-day  only  admit  two  degrees  of  retroversion, 
although  Hunter  admitted  three. 

First  Degree. — The  uterus  is  inclined  backward,  so  that  its  fundus  is 
in  contact  with  the  upper  part  of  the  sacrum,  the  cervix  resting  behind 
the  symphysis  pubis,  but  being  accessible  to  the  finger. 

Second  Degree. — The  fundus  has  executed  an  almost  complete  revolu- 
tion and  has  descended  so  far  into  the  hollow  of  the  sacrum  as  to  become 
accessible  to  the  finger,  or  even,  when  the  labia  are  pressed  open,  to  be 


DISEASES    OF    PREGNANCY. 


209 


seen  distending  the  posterior  vaginal  wall.  The  cervix  is  so  high  behind 
the  pubes  that  the  finger  no  longer  reaches  it.  Ordinarily  the  second  de- 
gree succeeds  the  first,  and  this  is  particularly  true  of  the  chronic  or  slow 
form.  But  the  pliysiological  backward  inclination  of  the  uterus,  during 
the  first  three  months,  must  not  be  mistaken  for  a  retroversion.  After 
the  third  month,  the  uterus  tends  to  quit  the  true  pelvis,  straightening 
itself,  and  approaching  more  nearly  to  the  axis  of  the  superior  strait. 
But,  if  it  encounters  an  obstacle,  whether  this  be  a  too  prominent  sacro- 
vertebral  angle  or  a  sigmoid  flexure  filled  with  faeces,  the  fundus  is  pushed 
backward  while  the  cervix  tends  to  approach  the  symphysis.  Intestinal 
and  vesical  disturbances  now  appear,  (Fig.  17)  accompanied  by  feelings 
of  weight,  of  traction  and  of  pains  in  the  loins,  while  examination  enables 


Fig.  17. — Retroversion  of  the  Uterus.  Gangrene  of  the  Detached  Mucous  Membrane  of 
THE  Bladder  and  of  a  Part  of  the  Muscular  Coat. — /,  Intestine.  U,  Uterus.  V.  Bladder.  W, 
Vagina.    MV,  Gangrenous  mucous  membrane  of  the  bladder.  . 

one  to  discover  uterine  displacement.  Women  walk  and  stand  with  difii- 
culty,  and  these  symptoms  becoming  aggravated  and  retention  of  urine 
becoming  complete,  the  disease  passes  into  the  second  degree. 

Salmon  thinks  that  an  effort  or  some  injury  is  necessary,  in  this  case, 
on  which  point  Depaul  does  not  agree  with  him.  When,  however,  retro- 
version is  suddenl}''  produced,  observation  shows  it  to  be  always  due  to 
violence,  to  efforts,  to  fatigues  or  to  traumatism.  Then  the  acute  symp- 
toms are  speedily  developed,  and  more  or  less  intense  pain  occurs  at  the 
moment  when  the  displacement  takes  place. 

The  chief  symptom  of  retroversion  is  retention  of  urine,  and  it  is  never 
wanting  in  the  second  degree.  The  retention  is  generally  complete,  and 
the  bladder  may  be  much  distended.  Sometimes  there  is  incontinence 
Vol.  11—14 


210 


A   TREATISE    OlST    OBSTETRICS. 


from  overflow.  The  urine  is  red,  strong-smelling,  and,  sometimes,  colored 
witli  blood.  There  is  usually,  also,  retention  of  faeces,  but  it  is  less 
marked,  and  we  often  feel  fscal  tumors  through  the  abdominal  wall. 
The  patients  complain  of  acute  pain  in  the  loins,  the  groins  and  the  ab- 
domen, and  of  weight  at  the  perineum.  Fever,  anorexia,  thirst,  insom- 
nia, emaciation  and  general  debility  then  ensue. 

Palpation  shows,  above  the  umbilicus,  an  elastic,  fluctuating  tumor  be- 
neath the  abdominal  wall,  in  which  no  foetal  member  can  be  distinguished 
and  in  which  ballottement  is  not  present.  If  the  catheter  is  used,  which 
may  be  difficult,  the  tumor  disappears  and  we  reach  the  viterus,  but  it  is 
impossible  to  bound  it  or  to  map  out  the  fundus.  On  palpation,  we  some- 
times feel  only  a  single  tumor,  formed  by  the  retro  verted  uterus  pushing, 
backward  the  posterior  vaginal  wall.     More  rarely,  there  are  two  tumors. 


Fig.  18. — Retroversion  of  the  Gravid  Uterus. 


one  behind,  which  is  the  uterus,  and  the  other  in  front,  which  is  the. 
bladder  (Fig.  18).  G-enerally  the  finger  does  not  find  the  cervix,  and, 
sometimes,  wg  only  find  it  with  great  difficulty  above  the  pubes,  and  then 
one  can  often  only  feel  one  of  the  lips  of  the  cervix.  Finally,  one  some- 
times finds  the  fundus  of  the  retro  verted  organ  presenting  the  character- 
istics of  the  pregnant  uterus. 

In  some  cases  there  exist,  simultaneously,  retroversion  and  retroflexion, 
and  then  another  difficulty  arises  for  the  diagnostician,  because  the  cervix 
may  be  displaced,  and  the  facility  with  which  one  reaches  the  cervix  dis- 
arms the  suspicion  of  a  retroversion.  Ordinarily  it  is  almost  inaccessible, 
but  rectal  touch  allows  us  to  examine  a  large  part  of  the  uterine  tumor 
and  to  appreciate  the  characters  of  this  tumor.  What  is  most  striking,  at 
first,  is  the  slight  depth  at  which  we  encounter  this  tumor,  and,  in  exam- 
ining with  care,  we  see  that  it  is  not  continuous  with  the  uterus,  which  is 


DISEASES    OF    PREGNANCY.  211 

only  displaced  and  flattened,  by  it.  Besides,  in  combining  vaginal  and 
rectal  palpation,  we  feel  that  the  finger  in  the  rectum  is  only  separated 
from  that  in  the  vagina  by  the  thickness  of  the  folded  and  swollen  vaginal 
wall.  It  is  only  in  exceptional  cases  that  the  finger  can  reach  beyond  the 
end  of  the  tumor. 

.  In  view  of  the  existing  stage  of  pregnancy,  auscultation  gives  no  in- 
formation, but  we  generally  discover  the  uterine  souffle.  In  exceptional 
cases,  on  separating  the  labia,  we  have  been  able  to  perceive  the  tumor, 
but,  in  general,  that  which  is  striking  in  these  cases  is,  often,  the  swelling 
of  the  labia  majora  and  minora  and  the  presence  of  a  vaginal  prominence 
large  enough  to  pass  for  a  prolapse  of  the  vagina. 

When  the  affection  has  reached  its  acme,  and  incarceration  has  taken 
place,  all  the  above  symptoms  are  aggravated.  The  pain  becomes  intoler- 
able, the  fever  is  more  and  more  intense,  and  to  retention  of  the  urine  and 
of  the  fgeces  are  joined  emesis,  singultus,  delirium,  irregularity  of  the 
pulse  and  a  state  of  prostration  and  adynamia,  more  or  less  pronounced, 
with  emaciation  and  exhaustion  of  the  patient.  If  abortion  does  not  set 
a  limit  to  these  accidents,  gangrene  of  the  bladder  and  rupture  of  the 
uterus  aggravate  the  situation,  or  even  result  in  death. 

Diagnosis. — This  embraces,  according  to  Salmon,  five  problems. 

First. — The  diagnosis  between  retroversion  of  the  gravid  utervis  and 
intra-uterine  fibrous  tumors,  in  a  healthy  or  in  a  retrovertcd  uterus. 
Fibroids  are  distinguished  by  the  hemorrhages,  the  slow  ])rogress  of  the 
disease,  the  resistance  of  the  cervix  compared  to  the  softness  of  preg- 
nancy, and  the  statements  of  the  patients  relative  to  the  existence  of  an 
old  tumor. 

Second. — The  differential  diagnosis  between  retroversion  of  the  preg- 
nant uterus  and  tumors  of  the  pelvis  or  of  the  abdominal  cavity.  This 
is^  sometimes,  very  diflflcult,  as  the  diagnostic  errors,  reported  by  various 
authors,  demonstrate.  The  characteristic  which  deserves  particular  at- 
tention is  the  retention  of  the  urine  and  the  possibility  of  generally  pass- 
ing the  finger  behind  the  pubes.  The  concomitant  symptoms  of  preg- 
nancy, but  especially  the  character  of  the  cervix,  will  often  make  the 
diagnosis.  Ketroversion  has  also  been  confounded  with  extra-uterine 
pregnancy,  ovarian  tumors  and  retro-uterine  hematocele. 

Tliircl. — The  differential  diagnosis  between  simple  pregnancy,  with 
retention  of  urine,  and  pregnancy  with  retroversion. 

Fourth.' — The  diagnosis  between  retroversion  during  normal  pregnancy 
and  retroversion  in  cases  of  hydatidiform  moles.  In  Salmon's  case  there 
was  no  retention. 

Fifth. — Finally,  the  diagnosis  between  retroversion  of  the  gravid  uterus 
and  retroversion  of  the  unimpregna,ted  uterus. 

The  differential  diagnosis  of  extra-uterine  pregnancy  really  presents  the 
greatest  difficulty,  and  we  shall  return  to  the  subject  under  that  heading. 


212  A   TREATISE    ON    OBSTETRICS. 

Prognosis. — This  is  always  very  grave,  but  is  more  so  in  proportion  as 
pregnancy  is  far  advanced,  for  the  complications  are  then  more  grave  and 
develop  more  rapidly,  and  the  treatment  is  more  difficult  of  application. 
Although  the  affection  often  ends  in  recovery,  it  may  also  end  in  abor- 
tion and  in  death  from  peritonitis,  from  gangrene  of  the  bladder,  from 
rupture  of  the  uterus  and  from  partial  gangrene  of  that  organ.  In  some 
cases,  the  fundus  uteri  has  contracted  adhesions  to  the  rectum,  a  com- 
munication has  formed  between  these  two  organs,  and  the  disintegrated 
foetus  has  been  expelled  piece-meal  through  the  bowel.  In  a  very  inter- 
esting case,  which  we  saw  at  the  Olinique,  the  diagnosis  was  doubtful,  and, 
in  spite  of  two  examinations,  Depaul  hesitated.  An  examination  to  de- 
cide regarding  intervention  was  appointed  for  the  following  day,  when, 
during  the  night,  the  woman  fell  out  of  bed.  The  disturbances  ceased 
as  if  by  magic,  but  the  patient  was  confined  in  the  forenoon.  This  was, 
probably,  a  case  of  spontaneously  reduced  retroversion. 

Treatment. — There  are,  according  to  Depaul,  three  methods. 

First:  Expectation — i.e.,  leaving  the  uterus  in  its  acquired  position, 
treating  complications,  destroying  probable  causes  of  retroversion,  or,  at 
least,  removing  obstacles  opposed  to  reduction.  Thus:  1st,  catheterism, 
which  is  not  always  easy  and  sometimes  demands  the  use  of  the  fine  elas- 
tic sound  in  place  of  the  ordinary  catheter,  and  is  to  be  repeated  three 
or  four  times  in  the  twenty- four  hours.  2d,  combatting  constipation, 
by  enemata  given  through  a  long  canula,  but  particularly  by  laxatives, 
especially  castor  oil.  Depaul  does  not  believe  that  the  position  of  the  woman 
has  any  influence,  at  least  in  severe  cases.  If  complications  occur,  resort 
to  the  second  method. 

Second:  Manual  Eeductio?i. — This  is  effected  either  by  the  rectum  or 
the  vagina,  with  one  or  two  fingers  or  even  the  whole  hand.  Gosselin 
used  the  first.  All  these  measures  have  been  successful,  but  the  result 
is  sometimes  only  obtained  by  their  combination  and  by  repeated  at- 
tempts. 

Third:  IJie  Instrumental  Method. — The  best  known  instrument  is 
Evrat's  baguette,  introduced  by  the  rectum.  Then  come  the  spatula  of 
Petit,  Eoederer's  spoon,  pessaries,  bladders  introduced  empty  and  then 
distended,  and  the  lever.  If  these  means  fail,  recourse  must  be  im- 
mediately had  to  artificial  abortion.  [The  simplest  and  most  effective 
method  of  replacing  the  retroverted,  flexed  uterus,  is  to  make  the 
patient  assume  the  knee-chest  position,  lift  up  the  perineum  by 
means  of  Sims's  speculum,  and  then,  very  exceptionally,  pneumatic 
pressure  and  gravity  will  replace  the  uterus.  If  not,  pressure  may 
be  made  on  the  fundus  in  the  posterior  cul-de-sac,  by  a  sponge  pro- 
bang  or  roll  of  cotton  held  in  the  dressing  forceps.  Occasionally,  especially 
near  the  end  of  the  third  month  and  after,  it  will  be  necessary  to  dislodge 
the  fundus  from  under  the  sacral  promontory  before  it  can  be  replaced. 


DISEASES    OF   PREGNAISTCY.  213 

This  is  accomplished  by  hooking  a  tenacuhim  in  the  anterior  lip  of  the 
cervix  and  pulling  downwards.  Unless  the  fundus  is  adherent  or  the  sacral 
promontory  very  projecting,  these  measures  will  suffice.  After  rej)0si- 
tion,  a  suitable  retroversion  pessary  should  be  worn  till  the  end  of  the 
fourth  month. — Ed.] 

Sacculation  of  the  Uterus. 

Partial  retroversion,  or  sacculation  of  the  .  uterus,  is  an  unusual  form 
assumed  by  the  pregnant  uterus,  which  has  furnished  Depaul  the  occa- 
sion for  a  very  complete  work  from  which  we  have  borrowed  the  following 
description. 

Depaul  keeps  the  name  sacciform  dilatation  of  the  jDOsterior  wall,  for  this 
modification  of  the  shape  of  the  uterus  has  a  special  origin  and  depends 
neither  upon  a  simple  flexion,  nor  upon  any  other  change  in  the  uterine 
axis.  The  explanation  is  found  in  the  unequal  growth  of  different  parts 
of  the  organ.  The  cases  collected  by  Depaul,  from  his  private  practice, 
and  from  different  authors,  are  not  numerous,  for  they  are  only  a  dozen, 
and  one  of  these  was  erroneously  diagnosticated.  So  it  is  a  rare  phenom- 
enon, but  it  only  deserves  the  more  attention  on  this  account,  because  of 
the  difficulties  of  the  diagnosis  and  of  the  dangers  for  both  mother  and 
child  which  it  entails.  Depaul  begins  by  stating  that  certain  parts  of 
the  uterus  grow  proportionately  much  more  than  others,  and  that,  gener- 
ally, the  anterior  wall  developes  much  more  fully  than  the  posterior  one. 
But,  exceptionally,  this  abnormal  development  may  occur  in  the  posterior 
wall.  In  this  case,  if  the  presenting  foetal  part  is  engaged  in  the  pelvis,  it 
must  push  before  it  this  posterior  wall  of  the  inferior  uterine  segment. 
The  cervix,  instead  of  being  directed  backward,  is  tuined  forward  toward 
the  symphysis  which  it  touches.  It  is  much  higher  in  the  pelvis  than  the 
posterior  part  of  the  inferior  segment  of  the  uterus,  which  descends 
toward  the  vulva,  forming  a  tumor  which  is  in  contact  with  the  hoUow 
of  the  sacrum,  and  variable  in  form,  in  accordance  with  the  part  of  the 
foetus  which  it  encloses.  In  the  case  of  Parise  and  Depaul,  hypertrophy 
and  tension  of  part  of  the  circular  fibres  of  the  external  os  were  super- 
iadded. 

Pathogeny. — Depaul  denies  any  causative  relation  between  this  condi- 
tion and  retroversion,  for  the  latter  occurs  in  the  first  months,  and  saccu- 
lated dilatation  in  the  last  two  months.  Without  denying  that  kyphosis 
may  have  some  etiological  influence,  as  some  authors  say,  he  states  that 
nothing  of  the  sort  existed  in  the  cases  he  has  seen.  He  further  rejects 
constipation,  and  the  consequent  straining  efforts,  invoked,  as  causes,  by 
Billi,  and  partial  retroversion,  suggested  by  Frank.  He  shows  that  Mende 
first  adopted  the  idea  of  primary  dilatation  of  the  posterior  wall,  suggested 
by  Kiwisch  and  Scanzoni,  and  that  the  opinion  of  Chailly  and  Hyernaux 
relative  to  abnormal  insertion  of  the  cervix  into  the  inferior  uterine  seg- 


214  A   TREATISE    ON    OBSTETRICS. 

ment,  rests  upon  no  anatomical  basis.  Depaul  believes  that  the  deformity- 
depends  upon  uterine  flexions,  particularly  antellexions  which  antedated 
pregnancy.  If  pregnancy  occurs  in  these  cases,  the  posterior  wall,  no 
longer  in  its  normal  state,  will  become  much  more  hype.rtrophied  than 
the  anterior,  because,  owing  to  the  character  of  its  tissues,  it  cannot 
respond  so  fully  to  the  stimulus  of  fecundation.  The  disproportion  ex- 
isting before  pregnancy  will  persist  and  even  be  increased.  The  posterior 
wall  will  be  more  and  more  depressed  into  the  pelvic  cavity,  the  anterior 
will  rise  in  the  same  proportion,  and  thus  the  cervix  will  come  to  be 
placed  against  the  upper  border  of  the  symphysis  or  even  several  finger- 
breadths  above  it. 

8igns  and  Diagnosis. — Abdominal  palpation  shows  that  the  anterior 
wall  is  not  so  prominent  or  so  uniformly  rounded  as  usual,  and  that  it  is, 
sometimes,  a  little  flattened.  If  the  bag  of  waters  is  broken,  one  may  see 
the  outlines  of  the  foetus.  If  the  lower  foetal  part  has  not  engaged,  which 
is  the  exception,  it  forms  a  prominence  above  the  pubes,  in  front.  On 
palpating  in  front,  we  see  that  the  posterior  part  of  the  uterus  is  largely 
developed,  and  has  occupied  all  the  available  space  in  the  corresponding 
part  of  the  abdominal  cavity.  Generally,  even  when  the  patients  reach 
full  term,  which  is  not  always,  the  volume  of  the  organ  does  not  seem  to 
correspond  to  the  period  in  question.  The  finger  introduced  into  the 
vagina  shows  the  posterior  vaginal  wall  to  be  very  short,  which  is  the 
reverse  of  the  normal  state.  The  corresponding  cul-de-sac  is  effaced,  and 
this  wall  drawn  forward  seems  to  end  in  the  prominent  part  of  the  foetal 
tumor.  The  finger,  instead  of  entering  deeply  to-  encircle  the  tumor, 
passes  obliquely  from  below  upward,  and  from  behind  forward,  and  is  con- 
ducted, in  spite  of  itself,  toward  the  centre  of  the  pelvis.  Here,  again, 
the  shortness  of  the  posterior  vaginal  wall  is  not  real.  The  upper  part 
covers  the  foetus  and  the  cul-de-sac  is  lifted  above  the  symphysis,  with  the 
cervix.  In  following  the  anterior  vaginal  wall,  we  seek  long  and  vainly 
for  its  upper  end,  and  therefore  for'  the  anterior  cul-de-sac.  Sometimes 
we  do  not  succeed,  even  with  two  fingers,  and  it  is  in  these  cases  that  the 
utility  of  introducing  the  whole  hand  is  apparent.  But  this  is  not  always 
possible,  even  with  chloroform,  and  the  deep  position  of  the  tumor  ob- 
structs the  movements  of  the  hand.  It  has,  in  some  cases,  been  impossi- 
ble to  reach  the  anterior  cul-de-sac,  and  it  has  been  necessary  to  use  a 
flexible  rod  passed  upward,  behind  the  pubes.  "When  we  have  once  reached 
the  OS,  we  find  it  closed  or  partly  opened,  softened  or  indurated,  directed 
forward  or  downward,  and  more  or  less  mobile.  The  bladder,  being  for- 
cibly drawn  upward  and  forward,  occupies  an  unusual  position,  and  to 
penetrate  its  cavity,  the  sound  should  be  exceptionally  long.  The  stretched 
urethra  is  in  close  proximity  to  the  posterior  wall  of  the  symphysis,  and 
to  find  its  external  orifice,  it  must  be  sought  much  higher,  for  it  is,  as  it 
were,  hidden  behind  the  anterior  pelvic  wall.     The  differential  diagnosis 


DISEASES    OF   PREGNAJSTCY.  215 

must  exclude  osseous  or  fibrous  tumors  attached  to  the  anterior  sacral 
wall,  fibromata,  cysts  of  tlic  recto-vesical  septum,  fibrous  tumors  of  the 
posterior  lip  of  tlie  cervix,  pelvic  hematocele,  retroversion,  ovarian  cysts, 
uterine  fibromata  affecting  the  body  Q.nd  the  upper  part  of  the  organ, 
fibromata  of  the  abdominal  wall,  or  of  abdominal  viscera,  extra-uterine 
pregnancy  and  complete  obliteration  of  the  cervix.  The  last-named  con- 
dition led  Depaul  into  error,  in  his  second  case. 

Prognosis. — This  is  very  serious,  but  there  is  a  difference  between 
cases  in  which  the  cervical  dilatation  is  moderate,  and  those  in  which  it 
is  excessive.  In  the  former  case,  labor  is  longer  and  the  cervix  dilates  less 
easily,  but  the  deviation  may  correct  itself,  little  by  little,  until  the  child 
can  enter  the  pelvis,  particularly  if  the  pelvic  extremity  presents.  The 
life  of  the  foetus  is  almost  always  sacrificed,  Frank's  case  forming  the  sole 
exception.  But,  when  the  cervix  is  drawn  forward  and  above  the  sym- 
physis, the  difficulties  are  much  greater.  The  part  of  the  foetus  contained 
in  the  sac  formed  by  the  posterior  wall,  receives  the  force  of  the  uterine 
efforts,  which  cause  the  tumor  to  descend  even  to  the  vulva.  The  uterine 
tissue  becomes  inflamed,  thin  and  painful,  and  may  even  be  lacerated  or 
become  gangrenous.  The  cervix,  placed  beyond  the  sphere  of  uterine 
action,  does  not  dilate,  even  at  the  end  of  several  days  of  labor.  Some- 
times the  posterior  lip  becomes  rigid  and  opposes  a  new  obstacle  to  explo- 
ration. Metritis  and  peritonitis  may  be  the  results  of  this  forced  labor. 
The  women  are  quite  exhausted,  and  putrefaction  of  the  child  being 
super-added,  when  the  membranes  have  been  ruptured  some  days,  aggra- 
vates the  situation.     Still,  the  majority  of  the  mothers  have  survived. 

Treatment. — The  conditions  under  which  we  are  called  are  very  varia- 
ble, hence  the  impossibility  of  prescribing  a  line  of  conduct  applicable  to 
all  cases.  The  indications  are  to  reach  the  cervix,  and  to  draw  it  down- 
ward. If  the  child  presents  by  the  feet,  to  draw  them  down  and  to  seek 
to  have  them  engage;  to  seize  them  with  a  noose  and  to  extract,  so  soon 
as  dilatation  is  complete;  to  see  if  the  tumor  can  be  displaced;  to  incise 
the  cervix,  if  it  is  rigid;  and  finally,  as  a  last  resort,  to  do  vaginal  hyster- 
otomy, i.e.,  to  open  the  inferior  segment,  through  the  vagina  and  to  thus 
extract  the  foetus. 


CHAPTER  III. 

DISEASES   OF   THE  OVUM. 

CONSIDEEED  as  a  whole,  the  ovum  represents  a  membranous  sac  com- 
posed of  two  membranes  peculiar  to  it,  the  amnion  and  the  chorion, 
and  of  one  membrane  of  uterine  origin,  the  decidual,  a  sac  which  contains 
the  foetus,  the  cord, the  placenta  and  the  amniotic  fluid.  Each  of  these  parts 
may  be  the  seat  of  lesions  forming  the  subject  of  this  chapter,  and  consti- 
tuting the  pathology  of  the  ovum.  We  shall  commence  by  the  study  of 
changes  in  the  decidua. 

Diseases  of  the  Decidua. 

Metritis  proper  is  rare  in  pregnancy,  as  all  authors  admit,  except  when 
there  is  retroflexion  or  retroversion.  Inflammations  of  the  decidua  are, 
however,  frequent,  and  maybe  acute,  as  in  the  infectious  diseases,  cholera, 
typhus  and  variola,  leading  through  apoplexy  of  the  membranes  to  early 
abortion,  to  destruction  of  the  ovum,  and  to  the  degeneration  called  fleshy 
mole.  Again,  the  inflammation  may  be  chronic,  and  then  presents  the 
three  following  essential  varieties:  1.  Chronic  diffuse  endometritis;  Z. 
Polypoid  endometritis;  3.  Catarrhal  endometritis,  or  hydrorrhoea  gravida- 
rum. 

1.    Glironio  diffuse  Endometritis. 

This  consists  in  the  development  of  connective  tissue,  partly  white  and 
partly  yellow,  forming  a  granulation  tissue  and  causing  thickening  and 
induration  of  the  decidua.  There  is  hyperplasia  of  the  mucous  mem- 
brane, in  which  the  subjacent  muscular  fibres  are  involved,  with  the  for- 
mation of  cysts.  (Spiegelberg) .  Schroeder  considers  it  to  consist  in 
chronic  diffuse  proliferation  of  the  decidua  vera  and  reflexa.  The  mu- 
cous coat  is  thickened  by  the  aggregation  of  the  large  cells  of  the  deci- 
dua; or,  as  a  result  of  their  proliferation,  the  mucous  membrane,  particu- 
larly the  deeper  layers,  presents  a  cavernous  or  cystic  structure.  These 
changes  cause  the  death  of  the  foetus,  and  abortion  may  even  occur  from 
the  irritation  of  the  aterine  nerves,  occasioned  by  the  inflammation  of  the 
mucous  membrane.  In  other  cases  the  inflammation  is  more  chronic, 
the  nutrition  of  the  ovum  is  unaffected,  pregnancy  advances  to  full  term, 
and  inflammation  is  only  recognized  by  examination  of  the  membranes. 
M.  Haschewarowa  found,  in  the  thick  membranes  of  a  foetus  at  term,  not 
only  proliferating  connective  tissue  and  decidual  cells,  but  also  newly- 


DISEASES    OF    THE    OVUM.  217 

formed,  smooth  muscular  fibres.     Often  this  inflammatory  thickening  is 
merely  partial. 

Hofe  described  some  deciduEe  in  which  inflammation  had  caused  pro- 
tuberances as  large  as  a  grain  of  wheat,  or  larger.  In  some  cases,  accord- 
ing to  Schroeder  and  Spiegelberg,  the  proliferation  of  the  decidual  cells  is 
secondary  to  death  of  the  foetus.  This  happens,  according  to  Duncan, 
particularly  in  those  cases  where,  after  the  death  of  the  foetus,  the  ovum 
is  retained.  This  is  the  adhesive  endometritis  of  Braiin.  Accordinsf  to 
him,  the  proliferation  of  Friedlander's  large  cells  does  not  occur  in  the 
decidua  proper,  and  is  accompanied  by  hyperemia  and  extrav'asations  in 
the  placenta.  The  disease,  he  says,  is  characterized  during  pregnancy 
by  the  fact  that  the  foetal  movements  are  painful,  and  that  the  women 
experience  violent,  colic-like  pains  described  under  the  name  of  uterine 
rheumatism.  It  is  chiefly  caused  by  exposure  to  cold.  When  the  disease 
mainly  attacks  the  utero-placental  mucous  membrane,  it  is  much  more 
dangerous  for  the  foetus,  and  in  these  cases  abortion  is  generally  caused 
by  the  persistent  irritation  and  by  the  destruction  of  the  mucous  mem- 
brane through  hemorrhages.  At  the  moment  of  delivery  it  may  occasion 
difficidty  by  causing  adhesions  of  the  placenta.  M.  Haschewarowa  has 
given,  as  causes,  syphilis,  or  a  chronic  endometritis  antedating  pregnancy, 
efforts  and  difiicult  labor. 

2.  Polypoid  Endometritis. 

This  condition^  which  is  only  a  more  advanced  degree  of  the  cases. 
reported  by  Hofe,  is  characterized  by  thickening  of  the  mucous  mem- 
brane, which  may  attain  double  or  triple  its  normal  thickness,  and 
by  prominences  of  different  form  and  size,  sometimes  from  one-fifth  to 
one-half  an  inch  high,  but  smooth,  which  are  situated  on  the  surface  of 
the  mucous  membrane.  (Fig.  19.)  The  excrescences  are  sometimes 
pediculated  and  sometimes  sessile.  Sometimes  they  form  thick  kernels. 
The  uterine  surface  is  rough  and  covered  with  coagula.  According  to 
Schroeder,  the  uterine  glands  are  absent  on  the  bright  red  surface  of  these 
excrescences,  but  are  very  apparent  on  all  other  parts  of  the  mucous  mem- 
brane. The  whole  mucous  membrane,  particularly  in  the  papillae,  is  very 
vascular.  Spiegelberg  admits,  as  does  Schroeder,  that  the  outgrowths 
are  more  vascular  than  the  rest  of  the  membrane.  The  glandular  ori- 
fices are  not  numerous,  are  sometimes  absent,  and,  particularly  at  the  ex- 
tremity of  the  prominences,  have  a  small  diameter.  According  to  Vir- 
chow,  the  microscope  shows  that  the  proliferating  tissue  is  the  interstitial 
tissue  of  the  mucous  membrane.  In  the  midst  of  a  slightly  fibrillarj 
tissue,  we  see  large  stellate  cells  which,  on  vertical  section,  appear  as 
thick  fasciculi.  According  to  Spiegelberg  and  Dohrn,  the  characteristic 
elements  of  the  proliferation  are  the  decidual  cells,  which  are  remarkable 
for  their  large  size  and  their  large  nucleus.     They  are  concentrically  ar- 


218 


A   TREATISE    ON   OBSTETRICS. 


ranged  around  the  vessels  and  cause  constriction  of  tlie  glands.  In  some 
isolated  cases,  where  the  decidua  vera  was  absent,  the  change  has  been 
seen  in  the  reflexa.  (Dohrn. )  It  has  never  been  observed,  save  upon 
young  abortive  ova.  Almost  always  the  villi  are  secondarily  changed. 
The  embryo  has,  usually,  disappeared.  Upon  an  ovum,  observed  by  Vir- 
chow,  they  constituted  long  epithelial  projections,  generally  very  fine.  In 
Gusserow's  case  they  ended  in  club-shaped  extremities,  while  the  ova 
seen  by  Dohrn  and  Miiller  showed  the  beginning  of  a  multiple  myxoma 
of  the  villi.  r 


Fig.  19.— Polypoid  Endometritis.  (After  Firc/ioK'.)— Foetal  surface  of  decidua.  a,  Openings 
of  the  glands.    6,  Larger  openings,    c,  c,  Projections  or  vegetations.    One  of  them  is  cut  open. 

The  etiology  is  obscure.  In  Virchow^s  case  there  was  a  syphilitic  his- 
tory, but  in  the  other  cases  there  was  none.  In  some  of  the  cases  it  seems 
that  the  lesion  was  only  the  result  of  an  endometritis,  of  an  irritation  of 
the  mucous  membrane,  preceding  pregnancy.  The  changes  in  the  cho- 
rion, as  those  of  the  foetus,  are  only  secondary.  Speigelberg,  even,  rather 
considers  this  alteration  secondary. 

3 .  Gatarrlial  Endometritis.  — Hydrorrhma . 
The  opinion,  entertained  to-day  by  the  German  authors  Schroeder,  Spie- 
gelberg  and  Braiin,  is  that  chronic  inflammation  of  the  decidua  may, 
aside  from  cellular  proliferation,  produce  an  abnormal  secretion  called 
hydrorrhcea  gravidarum.  But  this  opinion  is  not  yet  accepted  by  all 
authors,  and  Stapf er,  after  reviewing  and  discussing  all  the  opinions,  con- 
cludes that  there  are,  perhaps,  two  forms  of  hydrorrhcea,  the  traumatic 
and  the  catarrhal.  His  work  is  the  most  recent  aad  complete.  We  bor- 
row, from  it,  the  following  description. 


DISEASES    OF    THE   OVUAr.  219 

The  aqueous  discharges  during  pregnancy  have  been  considered,  now 
as  uterine  dropsy,  now  as  dropsy  of  the  membranes,  now  as  premature 
rupture  of  the  membranes,  and  have  been  described,  under  the  titles  false 
waters,  hydrorrhoea  and  metrorrhoea.  Several  hypotheses  have  been  sug- 
gested regarding  the  seat,  the  source  and  the  nature  of  the  liquid. 

Seat. — /.  Betioeen  the  Uterine  Walls  and  tlie  Membranes. — A  case  of 
Duclos,  quoted  by  Basset,  seems  conclusive.  Here  two  full  sacs  and  one 
empty  one  were  found,  as  well  as  the  channel  leading  from  the  latter  to 
the  OS,  and  this  in  a  woman  who,  three  weeks  before,  had  suddenly  lost  a 
glassful  of  liquid,  and  had,  subsequently,  had  a  discharge,  drop  by 
drop.  This  is  the  anatomical  explanation  of  the  clinical  fact  reported  by 
ISTaegele  and  Geil.  A  secretion  occurs  and  accumulates.  The  membranes 
are  detached,  progressively,  as  far  as  the  os,  and  at  this  moment,  probably 
owing  to  a  painless  uterine  contraction,  the  pocket  is  suddenly  emptied. 
In  this  case  there  has  been  found,  on  the  internal  surface  of  the  uterus, 
an  opaque,  whitish  plaque.  Is  this  the  first  or  the  second  degree  of  the 
catarrhal  endometritis  of  Schroeder,  Spiegelberg  and  Braiin  ? 

II.  The  Water  collected  hetiveen  the  Membranes. — According  to  Mattei, 
in  two  out  of  three  cases  the  amnion  is  separated  from  the  chorion  by 
liquid,  not  only  in  the  early  weeks,  but  even  up  to  the  end  of  gestation. 
He  has  called  this  space,  thus  filled  with  liquid,  the  pocket,  the  amnio- 
chorial  sac.  According  to  others,  this  pocket  only  accidentally  exists  in 
cases  of  hydrorrhcea.  But  Naegele,  Basset  and  Chassinat  have  denied 
the  existence  of  this  sac,  and  shown  that,  even  in  hydrorrhcea,  there  is 
complete  adhesion  of  the  membranes.  Duclos  had  already  reported  that 
in  his  case.  Geil  overturned  this  opinion,  and  maintained  that  all  the 
water  escaping  from  the  uterus  during  pregnancy  or  immediately  after 
labor,  comes  from  the  space  separating  the  concavity  of  the  uterus  from 
the  convexity  of  the  chorion.  Stapfer  states  that,  in  a  case  seen  by  him, 
at  the  moment  when  he  was  palpating,  some  liquid  escaped  which  could 
only  come  from  the  internal  surface  of  the  uterus,  for  the  cervix  was  not 
dilated,  and,  during  labor,  two  pockets  were  successively  formed  and 
ruptured  by  Stapfer.  The  membranes  were  intact.  In  a  case  of  Bat- 
bedat,  however,  the  chorion  and  amnion  were  entirely  separated  on  one 
side,  and  incompletely  on  the  other.  The  amnion  on  its  external  sur- 
face, and  the  chorion  on  its  internal  surface,  were  covered  by  a  slight 
plastic  exudation,  such  as  is  seen  in  pleurisy.  That  seems  to  prove  that 
Naegele  and  Geil  were  too  positive.  Duges  stated  that  the  liquid  accu- 
mulated in  the  cavity  of  the  allantoisi  ! !  The  older  writers  held  that  the 
liquid  gathered  between  the  two  deciduae.  In  these  cases,  hydrorrhoea 
occurred  in  the  first  weeks  of  pregnancy.  The  two  deciduse  do  not,  in- 
deed, become  united  until  after  the  third  month. 
■     HI.  The  water  collects  in  an  hydatid. 

IV.  The  water  collects  in  a  cyst. 


220  A    TREATISE    ON"    OBSTETRICS. 

V.  The  collection  occurs  in  a  supernumerary  ovum. 

These  three  opinions  do  not  admit  of  discussion,  so  that  only  three 
opinions  remain:  1.  The  hydrorrhoea  of  the  first  weeks  (Tarnier)  occurs 
in  the  cavity  of  the  hydroperion.  The  liquid  collects  between  the  decid- 
ua  reflexa  and  the  decidua  vera.  2.  The  hydrorrhoea  of  the  last  months 
is  due  to  an  accumulation  of  liquid  between  the  decidua  and  the  chorion. 
3.  The  accumulation  is  between  the  chorion  and  the  amnion. 

Origin  of  the  Liquid. — I.  The  Liquid  comes  from  the  Amniotic  Cavity 
hy  Transudation. — Tarnier  andPinard  have  shown  that  this  transudation 
of  amniotic  liquid  is  possible  at  a  certain  stage  of  labor  under  the  influ- 
ence of  the  pains.  Is  the  same  true  of  pregnancy  ?  Stapf er  does  not 
think  so,  for  the  anatomical  conditions  are  not  the  same. 

II.  The  Liquid  comes  from  the  Uterine  Walls. — -This  is  the  view  of 
Naegele  and  Gell,  who  have  seen  these  escapes  of  water  persisting  after 
labor,  as  well  as  of  Chassinat,  Chailly  and  Mackenzie.  It  is  the  classical 
opinion.     Bnt  does  the  liquid  come  from  the  glands  or  from  the  vessels? 

1.  The  Liquid  comes  from  the  Glands. — This  is  the  opinion  of  Hegar 
and  of  Ketzius,  who  have  seen  hypertrophied  glands  on  the  membranes  of 
the  ova  of  two  women  who  had  had  hydrorrhoea.  The  decidua  vera  is  an 
organ  of  secretion,  and  hydrorrhoea  is  a  hypersecretion.  This  is  the  catar- 
rhal endometritis  of  Spiegelberg,  Schroeder  and  Braiin. 

2.  The  Liquid  comes  from  the  Vessels. — a.  The  liquid  is  serous  and  es- 
capes from  the  capillary  vessels,  torn  by  the  separation  of  a  part  of  the 
membranes  of  the  ovum.  This  is  the  opinion  of  Chassinat  and  of  Depaul, 
but  the  separation  of  the  membranes  is  not  explained,  h.  The  Liquid 
comes  from  the  Lymphatics. — Stapf  er  believes  that  the  fluid  is  not  pure 
lymph,  but  that  other  liquids  from  the  vascular  capillaries  or  the  amniotic 
cavity  are  mixed  with  the  lymph. 

III.  The  Liquid  conies  from  the  Amniotic  Cavity,  whence  it  escapes 
through  a  Tear  in  the  Membranes,  above  the  Uterine  Orifice. — The  only 
cases  are  those  of  Ingleby,  Biesing  and  Graef.  In  all  the  others  the 
membranes  were  intact. 

Nature  of  the  Liquid.  — This  is  very  little  understood.  Chassinat  found 
it  thin,  limpid,  transparent  and  viscid  from  albumin.  He  found  no  odor 
of  spermatic  fluid.  The  color  is  not  always  yellowish.  In  a  case  which 
we  reported  to  Stapfer,  the  liquid  had  a  slight  spermatic  odor,  was  not 
viscid,  was  but  slightly  turbid  and  contained  no  vernix  caseosa.  Boiling 
caused  slight  turbidity  but  not  nitric  acid:  hence  there  was  no  albumin.  In 
Gomes'  case  the  fluid  was  not  albuminous,  but  was  markedly  acid  and  con- 
tained much  epithelial  detritus.  After  evaporation,  crystals  of  chloride 
of  sodium  were  found,  but  no  nitrate  of  urea.  With  a  little  hydrochloric 
acid,  no  uric  acid  formed  even  after  twelve  hours.  A  little  ammonia 
caused  crystals  of  ammonio-magnesic  phosphate  to  appear  at  once  in  the 
field  of  tlie  microscope. 


DISEASES    OF    THE    OVUM.  221 

Frequency. — The  affection  is  rare.  Stapfer  could  only  collect  seventy 
cases.  It  has  been  particularly  seen  in  multipara?,  and  appears  at  inde- 
terminate periods.  It,  however,  seems  more  frequent  in  the  last  two 
months. 

Signs. — Typical  hydrorrhoea  has  the  following  symptoms:  A  woman 
after  the  sixth  month  suddenly  loses,  at  different  intervals,  a  jet  of  trans- 
parent, colorless  liquid,  slightly  tinging  the  linen,  making  it  stiff,  like  ascitic 
fluid,  giving  a  more  or  less  abundant  albuminous  precipitate,  and  fol- 
lowed by  an  oozing  more  or  less  marked  and  prolonged.  All  this  happens 
without  prodromal  symptoms  and  without  painful  uterine  contractions. 
Labor  occurs  at  term,  and  the  foetus  is  healthy.  The  membranes  are 
intact,  adherent,  opaque  in  one,  two  or  three  places. 

Local  Symptoms. — The  hydrorrhoea  begins  suddenly,  without  known 
cause,  at  night.  At  other  times,  the  abdomen  becomes  distended  before 
the  discharge,  the  patient  feels  tired;  then  painful  uterine  contractions 
follow;  a  jet  of  liquid  escapes  from  the  vulva;  the  pain  ceases  at  once,  and 
the  abdomen  subsides.  Geil  disputes  this  preliminary  increase  in  the  size 
of  the  abdomen  noticed  by  Hegar  and  Chassinat.  Generally  the  escape 
of  the  liquid  is  sudden,  but  sometimes  there  is  simple  oozing.  Some- 
times there  is  a  single  discharge,  or  there  may  be  a  repetition  which  may 
become  periodical.  The  quantity  of  liquid  varies  from  one  to  twenty 
ounces.  Naegele  has  seen  the  discharge  continue  thirteen  weeks.  In 
some  rare  cases  the  liquid  has  been  colored  by  blood,  and  sometimes  a 
slight  sanguinolent  discharge  has  preceded  the  aqueous  one.  There  are 
no  constitutional  symptoms. 

Biaynosis.— This  depends  on  the  source  of  the  liquids.  The  only  avail- 
able symptoms  are:  The  repetition  of  the  discharge,  the  non-appearance  of 
abortion,  the  existence  of  a  catarrhal  metritis  at  the  time  of  conception. 
In  one  case  we  observed  an  effacement  of  the  cervix,  coincident  with  an 
escape  of  liquid,  which  lasted  four  days.  Then  the  flow  ceased,  but  the 
cervix  remained  obliterated,  and  the  labor  took  place  after  sixteen  days, 
twenty  days  after  the  accident.  The  bag  of  waters  formed  and  broke 
spontaneously,  while  the  membranes  and  placenta  showed  nothing  par- 
ticular. Another  sign  is  the  presence,  in  the  liquid,  of  debris  of  vernix 
easeosa,  which  shows  the  presence  of  amniotic  liquid. 

Prognosis.  —This  is  good,  neither  pregnancy  nor  health  being  compro- 
mised. 

Treatment. — This  consists  in  keeping  the  patients  quiet  and  watching 
uterine  contractions,  if  they  occur. 

Diseases  of  the  Placenta. 
1.  Placentitis. 
The  disease,  described  by  Geoffroy  de  Montreuil,  Brachet,  Simpson,  Fer- 


222  A   TREATISE    ON"   OBSTETKICS. 

dinand  Eobert  and  Cauwenberglie,  under  the  title  of  placentitis,  is  an 
endometritis,  but  a  distinction  must  be  made  between  inflammation  of 
the  fcBtal  and  of  the  maternal  placenta.  Indeed,  excluding  the  observa- 
tions of  Brachet,  Stratfordt,  Dance,  Simpson,  Cruveilhier,  Wilde,  Dubois 
and  Desormeaux,  Eamsbotham  and  G-eoffroy  de  Montreuil,  inflammation 
of  the  foetal  placenta  has  not  been  demonstrated.  But  inflammation  of 
the  maternal  placenta  has  been  observed  and  constitutes  the  organized  ad- 
hesions of  Brachet;  the  placentitis  of  the  second  degree  with  efl:usion  of 
coagulable  lymph  on  the  uterine  surface  of  the  placenta  of  Simpson;  and 
the  metamorphoses  of  plastic  inflammatory  exudation  on  the  uterine  pla- 
cental surface  of  Ferdinand  Robert.  This  is  the  acute  inflammation  of 
Meckel;  the  chronic  inflammation,  the  primitiv3  or  secondary  chronic 
endometritis  of  Braiin,  Schroeder  and  Spiegelberg;  the  interstitial  endo- 
metritis of  Hegar  and  Maier,  in  which  the  villi  are  agglutinated  and  com- 
pressed by  the  hypertrophied  decidua  serotina,  and  a  new  connective 
tissue. 

Here  is  their  microscopical  description,  after  Cauwenberglie:  The  fusi- 
form cells  which,  with  little  amorphous  intercellular  substance,  form  the  in- 
terstitial tissue  of  the  decidua  serotina  or  maternal  placenta,  are  larger 
than  normal,  but  in  various  stages  of  retrogressive  metamorphosis.  In 
the  points  where  the  change  is  most  recent,  the  cells  are  alone.  They 
are  now  regularl}?"  arranged,  side  by  side,  fusiform  as  in  their  normal  state, 
and  only  slightly  degenerated;  now  deformed,  rounded,  distended  by 
finely  granular  matter  or  by  a  fatty  granular  substance,  they  either  possess 
a  plain  nucleus  or  have  none.  Their  arrangement  is  less  uniform,  and 
between  them  is  free  fat  in  globular  masses  or  in  scattered  granules. 

As  the  affection  advances,  we  see  new  elements  appearing  between 
those  of  the  interstitial  tissue.  The  new  tissue  is  now  fibrillary,  finely 
reticulated,  its  meshes  being  filled  with  nuclei  and  cells,  now  fibroid, 
striated  or  homogeneous.  It  displaces  the  older  cells,  deforms  them  or 
leads  to  their  degeneration,  so  that  a  few  fatty  granules  alone  testify  to 
their  previous  existence.  In  many  places,  the  new  connective  tissue  quite 
displaces  the  old.  The  utero-placental  vessels  undergo  various  changes, 
the  constant  result  of  which  is  atrophy  and  degeneration  from  compres- 
sion, so  that  there  finally  remain  only  hard  and  whitish  foci,  comparable 
to  old  connective  tissue,  imbedded  in  the  spongy  mass  of  the  placenta. 
This  progressive  formation  of  connective  tissue,  on  the  uterine  surface 
and  in  the  placenta,  produces  induration,  the  plainest  result  of  which  is 
obliteration  of  tlie  foetal  and  maternal  vessels,  with  more  or  less  extensive 
thromboses  and  apoplexies. 

As  early  as  1842,  Devilliers,  in  1849,  Dance,  and  later,  Lesauvage, 
Breschet,  Dubreuilh  de  Montpellier  and  Jacquemier,  reported  congestions 
of  the  decidua,  leading  to  thickening  and  the  production  of  white,  pseudo- 
membranous concretions,  analogous  to  pleuritic  false  membranes.    (Dance 


DISEASES    OF    THE    OVUM.  223 

reported  a  layer  of  thickened  pus,  between  the  uterus  and  the  placenta). 
Congestions  of  the  uterus  may  lead  to  apoplexies,  that  is  hemorrhagic 
extravasations,  either  partial  or  general,  in  the  decidual  tissue  or  in  its 
cavity,  transforming  the  abortive  ovum  into  a  sort  of  coagulum,  as  almost 
all  observers  have  noticed.  If  the  hemorrhage  is  violent,  the  extravasa- 
tion may  occupy  not  only  the  thickness  of  the  decidute  and  their  cavity, 
but  may  also  rupture  the  membranes  and  peiletrate  their  interior. 
Devilliers  has  reported  a  case  which  he  considers  a  hypertrophy  of  the 
two  folds  of  the  decidua  greatly  congested  around  the  hypertrophied  pla- 
centa, the  first  cause  of  which  was  an  active  congestion  or  some  state 
peculiar  to  this  membrane.  The  result  is  congestion  of  the  uterus  fol- 
lowed by  a  granulo-fatty  degeneration  (interstitial  endometritis  of  Hegar). 
He  adds  that,  if  one  finds  pus  on  the  surface  of  the  decidua,  it  can  only 
come  from  the  inflamed  uterus. 

Hegar  states  that  the  changes  in  the  decidua  may  affect  all  parts  of  it, 
and  that  one  may  find,  successively: 


Fig.  20. — OvtJM  with  Atrophied  Decidua.  External  Surface  of  the  Decidua  Vera.  (After 
Spiegelberg). 

Atrophy,  which  is  not  serious,  except  when  it  affects  the  decidua  re- 
flexa  and  the  serotina,  for  simple  atrophy  of  the  decidua  vera  has  no  harm- 
ful result.  Miiller  calls  attention  to  the  fact  that  the  external  surface  of 
the  ovum  is  often  thickened,  but  smooth.  Now,  detachment  of  the  de- 
cidua in  the  first  half,  of  pregnancy  cannot  take  place  without  numerous 
lacerations  which  give  a  spongy,  rough  aspect  to  the  detached  surface, 
the  uterine  surface  being  thickened  while  the  foetal  surface  preserves  a 
soft  and  spongy  look.  Now,  in  certain  abortions,  the  two  surfaces  are 
alike,  being  formed  of  a  friable  tissue.  The  glandular  spaces  are  widened 
and,  later,  there  is  fatty  degeneration.  There  is  atrophy  and  deficiency 
of  the  decidua  reflexa,  which  may  also  affect  the  serotina.  In  this 
case,  says  Spiegelberg,  the  ovum  is  in  contact  with  only  a  small  part  of 
the  uterine  surface  and  we  find  the  serotina  notably  elongated,  as  it  were 
pediculated,  and  invaginated  into  the  decidua  reflexa  (Fig.  20),  In  the 
latter,  the  ovum  is  sustained  by  the  uterine  wall.  It  may  then  become 
detached  either  by  its  own  Aveight  or  by  uterine  contractions. 


224  A    TREATISE    ON    OBSTETRICS. 

If  the  clecidua  reflexa  is  originally  lacking,  tlie  villi  of  the  chorion  pro- 
liferate over  the  whole  area  of  the  decidua  vera,  and  then  we  may  have 
either  the  placenta  spread  out,  or,  as  the  uterine  development  is  not  reg- 
ular, a  placenta  prsevia.  Arrest  of  development  in  the  decidua  reflexa, 
or  its  premature  destruction,  is  more  frequent.  The  ovum  is  then  only 
covered  by  the  chorion  and  is  suspended  to  a  pedicle  of  the  serotina. 
The  pedicle  may  be  elongated,  producing  cervical  pregnancy  (Eokitansky). 
Hegar  also  mentions  hypertrophy,  which  may  affect  either  the  glandular 
tissue  (with  cyst-formation)  or  the  interstitial  tissue.  Finally,  there  may 
be  congestions  in  the  decidua,  with  hemorrhages,  as  reported  by  Devilliers, 
Jacquemier,  etc.  They  are  seated,  at  the  same  time,  on  the  external  sur- 
face, the  internal  surface,  and  in  the  thickness  of  the  mucous  membrane, 
as  well  in  the  decidua  vera  as  in  the  reflexa  and  in  the  serotina. 

Scanzoni  assumes  a  communication  between  the  two  surfaces  through 
the  widened  glandular  orifices.  The  same  may  occur  between  the  decidua 
reflexa  and  the  chorion.  When  they  are  seated  in  the  serotina  they  ex- 
tend between  the  reflexa  and  the  chorion,  then  invaginate  the  chorion 
and  amnion  into  the  cavity  of  the  ovum,  and  the  fcetus  dies  from  com- 
pression, unless  it  was  dead  before.  Sometimes,  even  the  cavity  of  the 
ovum  bursts  and  the  blood  penetrates  into  the  amniotic  cavity.  If  the 
ovum  does  not  burst,  the  amniotic  fluid  is  reabsorbed  after  the  death  of 
the  foetus,  which  is  macerated  and  disappears.  The  only  remnant  of  the 
ovum  is  debris  of  the  funis.  This  is  Montgomery's  false  germ,  ova  two 
months  old.  If  the  ovum  bursts,  the  fcetus  may  be  expelled  without 
one's  knowing  it,  and  then  the  clots  and  membranes  are  expelled  later. 
If  expulsion  is  long  delayed,  the  clot  may  become  more  solid,  undergo 
the  changes  usual  in  effused  blood  and  be  expelled,  later,  as  the  so-called 
carnified  mole.  The  decidua  is  often  thickened,  hypertrophied  and  very 
adherent  to  the  uterine  wall.  This  accounts  for  the  long  sojourn  in  utero 
of  the  carnified  mole,  which  may  undergo  pigmentary  and  other  changes. 
When  the  chorion  and  the  amnion,  or  the  amnion  alone,  after  rupture  of 
the  chorion,  have  been  thus  dilated  by  the  extravasation,  they  form 
what  is  called  hemorrhagic  cysts  (Fig.  21),  which  enclose  a  sero-sanguinolent 
fluid  or  a  clear  fluid  colored  and  derived  from  the  blood  serum.  Carnified 
moles  are  usually  expelled  at  the  fifth  month  and  rarely  are  larger  than  an 
orange.  Sometimes  part  of  the  mole  remains  in  utero  and  may  become 
the  origin  of  fibrous  polypi. 

We  thus  see  that,  although  inflammation  of  the  maternal  placenta  is 
to-day  undoubted,  the  same  is  not  true  of  foetal  placentitis.  Cauwen- 
berghe  regards  it  as  doubtful;  Duchamp  admits  its  existence,  with  the 
reservation  that,  although  the  suppurative  form  is  doubtful,  the  chronic 
or  sclerotic  form  is  real.  It  shows  itself  in  fibrous  degeneration  of  the 
villi.  The  cases  of  so-called  abscess  of  the  placenta,  numbering  ten  in 
scientific  literature,  are  questionable,  for  not  one  of  the  authors  remem- 


DISEASES    OF    THE    OVU>r. 


225 


bered  to  analyze  the  pus,  and  it  is  more  than  probable  that  it  was  not 
genuine  pus  but  what  Eobin  has  called  pseudo-fibrinous  pus. 

2.   Changes  in  tJie  Chorion. 

The  maternal  placenta  is  formed  by  the  decidua  serotina.  The  foetal 
placenta  is  formed  by  the  villi  of  the  chorion  which,  having  originally 
covered  the  entire  surface  of  the  ovum,  atrophy  over  the  major  part  of 
the  surface,  while  they  ramify  and  develop,  ad  infinitum,  at  the  point 
corresponding  to  the  serotina,  where  they  become  imbedded  and  consti- 
tute the  vascular  mass  known  as  the  placenta.     To  study  changes  in  the 


Fig.  21.— Bloody  Mole,  with  Extravasations  and  Blood-cysts  on  the  Fcetal  Surface. 
(After  SpieQelberg.)—CS,  Clots.    KH,  Blood  Cysts. 

chorion  amounts  to  studying  the  lesions  of  the  placenta  and  the  reverse. 
Now,  these  changes  may  relate  to  each  of  the  placental  elements,  i.e., 
the  vessels  and  the  villi.     Let  us  successively  study  these  lesions. 

I.  Atrophy  of  the  Villi  of  the  Chorion. 

This  atrophy  occurs,  normally,  in  all  the  villi  not  destined  to  form  the 
placenta,  i.e.,  in  all  not  in  contact  with  the  serotina,  and  these  villi  may 
present  three  different  conditions: 

1.  They  are  vascular. 

2.  They  are  well-formed  and  hollow  but  non-vascular. 

3.  They  are  mal-formed,  and  this  has  prevented  their  vascularization. 
The  atrophy  is  different  in  the  vascular  and  in  the  non-vascular  villi. 

Ch.  Eobin  has  best  described  this  atrophy:  1.  If  the  villus  is  non-vas- 
cular, it  is  obliterated  and  undergoes  fatty  degeneration;  2.   If  the  villus 
is  vascular,  the  vessels  are  obliterated  and  the  villus  transformed  into 
fibrous  tissue,  composed  of  longitudinal  parallel  bundles  not  continuous 
Vol.  11—15. 


226  A   TREATISE    ON    OBSTETRICS. 

witli  the  tissue  of  the  wall  of  the  villus.  There  is,  also,  a  little  amorph- 
ous connective  tissue  and  fine  granulations,  besides  narrow  and  long 
nuclei,  longitudinally  directed  and  only  made  visible  by  acetic  acid. 

This  obliteration  occurs  in  the  villi  of  different  cotyledons  indifferently. 

In  many  villi,  after  obliteration,  we  find  that  the  parietes  contain  fatty 
granulations,  and  real  drops  of  oil,  mostly  spherical  or  oval.  They  are 
bright  yellow  at  the  centre  and  dark  at  the  periphery.  They  are  insol- 
uble in  acetic  acid  but  soluble  in  liquor  potassse.  They  are  either  irregu- 
larly dispersed  or  collected  into  groups. 

The  villi  of  the  decidua  serotina  are  developed,  ad  infinitum,  and  form 
the  placenta.  But  as  Cauwenberglie  justly  remarks,  the  disorders  of  the 
circulation,  manifested  during  the  development  of  the  villi,  differ  greatly 
from  those  obtaining  after  the  perfect  formation  of  the  placenta.  Au- 
thors, although  agreeing  about  the  former,  disagree  about  the  latter  period. 

Eigenbrodt  and  Hegar  have  noted  apoplectiform  destruction  of  the 
uterine  mucous  membrane,  both  in  pseudo-membranous  dysmenorrhoca 
and  on  abortive  ova  of  the  early  months.  During  this  time  the  mucosa 
is  thickened,  its  vessels  grow  large  and  numerous,  their  walls  are  thinned, 
they  coalesce  and  form  vascular  labyrinths  gorged  with  blood  as  the  re- 
sult of  physiological  congestion.  The  gradual  penetration  of  the  vessels' 
walls,  thinned  by  the  villi,  also  favor  rupture  of  the  vessels  and  extravasation 
(Oauwenberghe).  Hemorrhage  is  very  frequent  during  placental  devel- 
opment, and  may  be  primary  or  secondary  to  morbid  maternal  or  foetal 
states.  The  blood  comes,  then,  from  the  mother's  circulation,  and  is  sit- 
uated in  the  decidua  serotina. 

When  the  placenta  is  once  formed,  one  may  observe  either  simple  con- 
gestion, the  villi  presenting  no  changes,  or  hemorrhages,  apoplectiform 
extravasations,  always  due  to  changes  in  the  villi.  But  these  hemorrhages 
undergo  changes  greatly  altering  the  appearance  of  the  lesion,  hence  di- 
verse descriptions  and  different  opinions,  held  by  authors,  not  only  as  to 
the  existence  of  such  or  such  lesions  but  as  to  the  connections  between 
them.  Some  consider  the  lesions  of  the  villi  as  merely  secondary  to  the 
extravasations.  Others  consider  the  disease  of  the  villi  the  chief  element, 
and  attach  secondary  importance  to  the  hemorrhages.  Some  see  the 
source  of  the  hemorrhages  in  the  maternal  circulation  and  others  in  the 
foetal. 

II.   Extravasations. 

Jacquemier's  work  on  this  subject  is  the  most  complete.  He  claims 
that,  unless  arterial  lesions  exist,  the  hemorrhages  are  always  due  to  tear- 
ing of  the  veins,  either  in  the  placental  tissue  or  in  the  decidua,  outside 
of  the  placenta. 

The  seat  of  the  extravasations  depends  on  the  development  of  the  pla- 
centa and  the  time  of  the  hemorrhage,  and  the  hemorrhages  are  either 


DISEASES    OF    THE    OVUM.  227 

true  extravasations  or  what  are  called  by  Jacquemier  and  others  placental 
apoplexies. 

When  the  placenta  is  ftilly  formed,  the  bloocl,  extra vasated  in  the  pla- 
centa, cannot  extend  between  the  decidua  and  the  chorion,  but  accumu- 
lates on  the  external  surface  of  the  chorion  and  is  limited  to  the  lobe  in 
which  it  was  first  extravasated.  Later,  the  placenta  forms  a  compact 
mass,  and  the  blood,  not  being  able  to  reach  so  far,  forms  superficial  foci 
rarely  reaching  the  external  surface  of  the  chorion.  Occasionally,  lesions 
of  the  umbilical  vessels  are  merely  consecutive  to  those  orf  the  utero-pla- 
cental  vessels. 

The  extravasations  may  present  themselves  in  three  distinct  forms : 

1.  The  blood  is  contained  in  a  very  irregular  cavity.  The  neighboring 
tissues  are  infiltrated  and  colored  red.  The  hemorrhagic  foci  often  com- 
municate with  the  external  placental  surface,  which  is  torn.  They  are 
irregular,  being  sometimes  on  the  placental  border,  and  sometimes  in  its 
centre.  In  the  latter  case,  they  generally  extend  to  the  external  surface 
of  the  chorion  and  to  the  cord.  If  they  are  at  the  points  where  the  chief 
^ranches  of  the  funis  traverse  the  chorion,  the  blood  sometimes  infiltrates 
the  tissues  around  the  umbilical  vein  and  artery.  The  hemorrhagic  foci 
may  be  single  or  multiple  and  of  the  same  or  different  dates. 

Millet  is  opposed  to  these  views  and  thus  expresses  himself  in  his  thesis: 

''a.  The  extravasations  in  the  centre  of  the  cotyledons  come  from  rup- 
tured umbilical  vessels,  and  not  from  maternal  vessels. 

^'h.  The  supposed  false  membranes,  referred  to  by  certain  writers,  on 
the  uterine  surface  of  the  placenta,  and  regarded  as  an  inflammatory  exu- 
dation, are  only  heaps  of  epithelial  cells,  which  have  undergone  a  real 
hypergenesis,  or  hypertrophy,  at  certain  points." 

Certain  microscopists  have  found  aneurisms  of  the  umbilical  vessels,  at 
the  entrance  of  the  latter  on  the  foetal  side  of  the  placenta,  which  would 
explain  the  apoplectiform  extravasations. 

2.  There  is  no  proper  focus.  The  blood  is  infiltrated  in  one  or  more 
lobes.     It  may,  however,  be  more  abundant  at  some  places. 

3.  The  blood  is  in  regular,  circumscribed  foci,  the  number  of  which 
may  vary  from  two  or  three  to  twenty.  The  placental  tissue  around  them 
is  healthy.  Being  first  decolorized  at  their  circumference,  they  seem  en- 
veloped by  a  new  cyst.  There  are,  sometimes,  very  numerous  small  and 
regular  foci,  containing  coagula,  which  closely  resemble  seeds  of  black 
grapes,  and  which,  being  in  different  stages  of  transformation,  indicate 
recent  and  old  coagulations. 

These  extravasations  may  coexist  with  the  lesions  of  ordinary  uterine 
hemorrhages,  internal  or  external,  but  they  often  occur  alone  or  only  lead 
to  the  lesions  in  question  at  a  late  date.  Dubois  and  Desormeaux  make 
two  different  degrees  of  the  disease,  congestion  and  apoplexy  of  the  pla- 
centa.    The  congestion  may  lead  to  extravasations  in  the  placenta,  on 


228  A   TREATISE    ON    OBSTETRICS. 

either  placental  surface  or  between  the  decidual  membranes  and  the 
chorion.  The  congestion  may  result  from  disturbances  of  either  the  ma- 
ternal or  of  the  foetal  circulation.  Simpson  holds  this  view  and  Jacque- 
mier  rejects  it,  believing  that  hemorrhage  is  always  the  result  of  rupture 
of  utero- placental  veins. 

The  surface  of  the  placenta  is  violet  or  livid,  its  tissue  of  a  deep  pur- 
ple color,  its  vessels  full  of  venous  blood.  The  organ  is  larger  and  heav- 
ier. A  little  effort  on  the  patient's  part,  and  extravasation  occurs  from 
the  torn  vessels. 

In  the  first  three  months  it  occurs  between  the  chorion  and  the  de- 
cidua,  later  in  the  placenta,  and  nearer  the  fcetal  surface  as  pregnancy  is 
less  advanced.  This  is  the  placental  apoplexy  of  Cruveilhier,  the  utero- 
placental of  Jacquemier. 

In  true  placental  apoplexy,  is  it  the  rupture  of  the  umbilical  vessels, 
the  placental  parenchyma  or  the  utero -placental  vessels,  which  causes 
extravasation?  We  never  find,  except  in  the  case  of  Oazeaux  and 
Grisolle,  even  when  the  foci  are  near  the  foetal  surface,  any  torn  umbilical 
vessels. 

Is  there  rupture  of  the  parenchyma  or  laceration  of  the  utero-placental 
vessels  ?     This  is  the  sole  cause,  according  to  Jacquemier  and  Simpson. 

Their  seat  is  determined  by  the  very  structure  of  the  placenta,  which 
is  less  close  on  the  side  of  the  chorion. 

These  extravasations,  almost  always  multiple,  present  themselves  as 
foci,  generally  rounded  and  circumscribed.  Sometimes  their  form  and 
outline  are  irregular.  When  they  are  near  the  foetal  surface  of  the  pla- 
centa, and  the  blood  is  extravasated  between  the  decidua  and  the 
chorion,  the  latter  and  the  amnion  are  elevated  and  form  on  the  side  of 
the  cavity  of  the  ovum  an  hemispherical  or  conical  prominence.  The 
adhesion  of  the  clot  to  the  chorion  is  then,  sometimes,  very  intimate. 

Near  recent  extravasations,  the  placental  tissue  is  redder,  darker,  and 
this  state,  dependent,  perhaps,  upon  the  infiltration  of  a  certain  quantity 
of  the  extravasated  blood,  may  result,  also,  from  the  presence  of  a  num- 
ber of  diminutive  foci  around  the  chief  focus  or  of  little  clots  formed  in 
the  vessels.  The  color  of  the  blood  is  ordinarily  of  so  deep  a  brown  as 
to  simulate  melanotic  degenerations. 

In  other  cases  the  blood  is  decolorized,  becomes  successively  chocolate 
colored,  yellow,  reddish  or  brownish,  deep  yellow,  and  dirty  white  when 
the  coagulum  contains  only  fibrin. 

The  shrinking  of  the  clot,  and  the  expression  of  the  serum  into  the 
cavity  left  by  the  contraction,  might  simulate  a  serous  cyst. 

Einally,  the  tissue  near  the  extravasations  becomes  changed.  It  is  ex- 
sanguine, atrophied,  and  the  atrophy  may  become  general  if  the  foci  are 
multiple. 

Joulin,  186?,  thinks  the  foci  have  two  distinct  seats:  1,  the  utero-pla- 
cental mucous  membrane,  and  2,  the  placenta. 


DISEASES    OF    THE   OVUM.  229 

He  ascribes  the  effusion  to  fusion  of  the  vessels  and  to  partial  destruc- 
tion of  their  original  walls.  If  the  solution  of  continuity  be  considerable, 
the  pressure  of  the  liquid  may  cause  separation  and  the  blood  may  then 
enter  the  spaces  between  the  cotelydons  or  escape  externally.  The  pla- 
cental hemorrhages  are  seated  further  in  the  capillaries,  but  their  mechan- 
ism is  different.  He  ascribes  them  to  traction  on  and  laceration  of  the 
capillaries  from  their  displacement  and  their  change  of  direction  during 
the  enlargement  of  the  organ.  Perhaps  there  is  a  disease  of  the  capil- 
laries which  causes  the  hemorrhage.  However  it  be,  the  hemorrhages 
are  rarely  exactly  the  same  and  the  quantity  of  blood  is  very  variable. 
The  effusion  may  cover  the  whole  surface  of  the  ovum,  as  an  irregular 
layer,  sending  prolongations  into  the  depressions  hollowed  out  by  the  sep- 
aration. It  may,  in  other  cases,  be  in  smaller,  more  numerous,  isolated 
and  circumscribed  foci.  It  always  stops  at  the  inner  surface  of  the  organ, 
without  rupturing  the  epithelial  covering  of  the  uterus. 

The  appearance  of  the  clots  is  variable,  according  to  the  date  of  extra- 
vasation. They  are  black,  like  thin  jelly,  or  whitish,  or  in  yellowish- white 
resisting  plaques,  which  have  been  inappropriately  compared  to  scirrhous 
tissue. 

III.    Changes  in  the  Villi. 

Ch.  Eobin  considers  these  changes  as  the  consequence  of  the  natural 
development  of  the  villi  of  the  chorion  accidentally  affecting  the  villi  of 
the  placenta. 

A.  According  to  him,  we  sometimes  find  parts  of  different  cotyledons 
depressed,  hard,  friable  and  with  a  shreddy  irregular  surface.  This  tis- 
sue is  formed  of  villi  in  an  advanced  state  of  fibrous  degeneration.  The 
substance  of  the  chorion  proper  is  very  granular  and  often  thin.  The 
nuclei  are  less  numerous  than  in  the  normal  state.  The  granulations  are 
small  and  not  all  of  them  are  fatty.  The  villi  are  adherent,  and  between 
them  is  a  little  amorphous  tissue  and  a  few  granules. 

B.  In  some  placentse  the  cotyledons  are  separated  by  deep  furrows. 
The  tissue  is  harder  than  normal,  yet  friable,  is  gray,  yellowish-gray  or 
yellowish  white,  and  less  moist  than  normal.  At  a  deeper  level  the  tissue 
is  more  normal  but  denser,  less  red  and  less  moist.  These  parts  of  the 
tissue  are  composed  of  villi  obliterated  by  cellular  tissue,  but  many  of  the 
villi  have  their  own  normal  substance  or  contain  only  a  few  fatty  granu- 
lations. 

The  nuclei  are  generally  partly  or  entirely  absent  where  these  fatty 
granulations  are  in  contact,  but  this  is  not  constant. 

The  diseased  cotyledons  are  more  involved  on  the  uterine  surface  than 
on  that  of  the  chorion,  where  they  have  their  normal  softness,  humidity 
and  reddish  tint. 

The  fatty  deposit  is,  thus,  only  a  complication  of  the  obliteration  of  the 


230  A    TREATISE    ON    OBSTETEICS. 

villi,  which  is  accidental.  The  term  fatty  degeneration  is,  therefore,  not 
exactly  correct. 

Barnes  thus  describes  the  lesion,  in  the  cases  observed  by  him:  The 
maternal  placental  surface  is  deeply  divided  by  furrows,  resembling  cere- 
bral tissue  in  color  and  lobulation.  All  the  lobes  are  yellow  and  shiny, 
like  fat.  At  the  bottom  of  the.  furrows  the  color  is  red,  elsewhere  the 
placenta  is  pale.  The  fatty  aspect  is  more  marked  near  the  uterine  pla- 
cental surface,  and  the  microscope  shows  the  villi  there  to  be  more  ex- 
tensively changed.  The  villi  are,  however,  nowhere  perfectly  healthy, 
but  in  the  firmest  lobules  are  fragile  and  poorly  outlined,  and  their  ves- 
sels are  ruptured.  The  chorion  is  largely  destroyed,  and  the  nuclei  in  the 
walls  of  the  vessels  are  enlarged  and  filled  with  granules.  In  the  less 
diseased  parts  the  vessels  preserve  their  normal  volume. 

D'Outrepont,  Wilde  and  Kilian  regard  this  lesion  as  a  fatty  degener- 
ation of  the  placenta. 

So  soon  as  the  investigations  of  Eobin  were  published,  observations  were 
multiplied,  but  it  was  soon  noticed  that  the  facts  were  not  so  simple  as 
they  appeared  from  these  clear  and  precise  descriptions;  and  mixed  cases, 
i.e.,  cases  characterized  by  both  placental  apoplexy  and  fatty  degeneration 
of  the  villi,  were  cited. 

The  first  was  reported  ia  1854  by  Hiifelsheim  and  Laboulbene,  after 
that  of  Oh.  Robin,  who  maintained  that  these  lesions  are  independent  of 
each  other,  although  sometimes  coinciding.  He  held  that  obliteration 
of  a  few  placental  vessels  or  of  a  cotyledon  may  modify  the  whole  pla- 
cental circulation  and  thus  cause  hemorrhage,  but  that  the  lesion  itself  is 
independent  of  the  hemorrhage. 

Laboulbene  and  Hiffelsheini  came  to  the  following  conclusions: 

1.  There  may  be,  at  the  same  time,  apoplexy  and  obliteration  of  villi; 

2.  Apoplexy  does  not  cause  obliteration,  but  rather  the  reverse; 

3.  The  two  lesions  are  independent  ot  each  other. 

The  aj)pearance  of  the  diseased  cotyledons  has  sometimes  been  wrongly 
attributed  to  retrogressive  changes  in  coagula  about  which  the  authors 
do  not  agree. 

Jacquemier  says  that  the  serum  is  reabsorbed,  while  the  coagulum 
grows  dense  by  contraction.  The  pigment  gradually  disappears,  being 
first  lost  at  the  circumference,  unless  the  clot  has  been  formed  by  succes- 
sive additions.  Sometimes  the  coagulum  is  so  changed  as  to  be  unrec- 
ognizable or  to  simulate  cartilage,  cancerous  growths  or  tubercles,  nodu- 
lar or  diffuse. 

Sometimes  the  coagula  enclose  cavities  containing  blood,  and  sometimes 
they  are  soft  like  adipose  tissue  and  seem  to  be  encysted.  Often  the  um- 
bilical vessels  penetrating  the  coagula  are  obliterated.  When  the  blood- 
clot  is  large,  the  placental  tissue  is  firm  and  white  around  them,  and  one 
or  more  lobes  of  the  placenta  are  obliterated. 


DISEASES    OF    THE    OVUM.  231 

When  the  hemorrhage  lias  led  to  detachment  of  the  placenta,  the  circu- 
lation cannot  be  restored.  If,  however,  the  extravasation  is  small,  the 
blood  may  be  taken  up  and  the  serotina  reproduced.  The  latter  then  has 
new  vessels,  adherence  between  the  placenta  and  uterus  is  not  disturbed, 
and  the  umbilical  circulation  is  not  suspended. 

Ch.  Robin  states  that  fibrin  appears  in  two  forms,  according  to  the  man- 
ner of  its  coagulation.  The  first  is  the  thrombus,  formed  while  the  blood 
is  still  circulating,  as  in  the  case  of  cardiac  vegetations  and  in  aneurisms. 
The  thrombus  is  stratified  and  pale  in  color,  and  may  look  like  organized 
tissue,  but  never  has  fasciculi  as  does  fibrous  tissue.  It  has  no  capillaries 
and  never  grows,  but  either  enlarges  by  the  deposition  of  new  laminse, 
or  becomes  granular  and  is  reabsorbed.  Now,  it  is  not  even  this  form  of 
fibrin  which  is  found  in  the  placental  coagula. 

The  second  form  of  fibrin,  called  a  clot,  is  produced  during  life,  when 
extravasation,  apoplectic  or  otherwise,  takes  place,  or  Avhen  the  current 
of  blood  in  some  normal  or  pathological  cavity  is  interrupted.  The  clot, 
proper,  is  formed  of  fibrin  and  red  and  white  corpuscles,  is  softer  than  a 
thrombus,  is  friable  and  non-striated. 

These  are  the  coagula  found  in  the  placenta,  and  some  writers  speak  of 
their  organization  because  the  fibrin  resembles  formed  connective  tissue. 
Verdier  states  that  coagula  may  either  contract  and  become  permanent, 
be  destroyed  or  become  organized.  The  contraction  and  permanence  of 
coagula  is  simple  and  undisputable.  The  destruction  of  tlfe  clot  consists 
in  several  stages.  The  fibrin,  when  first  deposited,  gives  a  yellowish, 
lardaceous  look,  and  a  firm  yet  friable  feeling.  It  soon,  however,  becomes 
granular  and  presents  two  kinds  of  granules.  One  kind  is  proteid,  dis- 
solving in  alkalies  and  in  acetic  acid,  the  other  fatty,  resisting  these  re- 
agents. The  mass  then  becomes  soft  and  liquid,  resembling  pus,  and 
regarded  as  such  by  earlier  writers.  In  these  pyoid  masses  one  finds,  1, 
innumerable  fibrinous  and  fatty  granules;  2,  some  liquid;  3,  fatty  white 
corpuscles;  4,  granular  bodies  formed  either  by  simple  adhesion  of  fatty 
molecules  or  by  their  accumulation  in  a  white  corpuscle;  5,  hematoidin 
crystals. 

It  was  once  held  that  the  clots  could  become  organized. 

Hunter's  theory  of  organizable  pListic  lymph  was  soon  abandoned. 
Cruveilhier  denied  that  coagula  are  organized,  and  so  did  Robin,  but  Vul- 
.  pian  reaffirmed  the  old  theory,  and  Weber  describes  the  organization  of 
extravasated  blood.  In  the  coagula  of  ligated  vessels  the  white  corpuscles, 
in  a  few  days,  change  their  shape,  the  nuclei  divide,  they  send  out  slen- 
der prolongations  and  form  a  reticulum  like  that  of  connective  tissue. 
Then  capillaries  form  and  anastomose  with  neighboring  vessels,  the  red 
corpuscles  disappearing. 

Bustamente,  adopting  Dalton's  ideas,  says  that  the  villi,  with  their 
arterial  and  venous  channels,  plnnge  into  the  maternal  blood  from  which 


232  A   TREATISE    ON    OBSTETRICS. 

they  are  not  separated  at  all.  The  placenta,  according  to  him,  is  contin- 
ually bathed  in  the  mother's  blood,  which  extends  into  the  interstices  of 
the  cotyledons  like  liquid  into  a  sponge. 

Without  defining  the  nature  of  the  lesion  in  question,  the  author  des- 
cribes its  gross  and  microscopical  appearances. 

a.  External  Aijpearance. — The  lesion  occurs  either  in  scattered  foci  or 
in  more  or  less  extended  plaques,  which  may  be  far  separated,  near  to- 
gether, or  confluent.  The  color  varies  from  yellowish-white  to  blackish- 
red  or  black.     These  colors  are  due  to  metamorphoses  of  the  blood. 

h.  In  the  diseased  parts,  the  tissue  is  firmer,  yet  more  friable,  particu- 
larly in  cases  with  multiple  foci. 

G.  The  extent  is  variable.  Sometimes  the  foci  are  scattered  and  vary 
in  size  from  a  pea  to  a  nut;  sometimes  there  are  plaques,  which  may  be 
a  few  lines  broad  or  may  rarely  occupy  nearly  the  whole  placenta. 

d.  The  most  frequent  seat  is  the  border  or  the  neighboring  parts.  The 
next  is  the  foetal  surface,  and  then,  in  order,  the  whole  thickness  of  the 
organ,  the  uterine  surface,  the  centre  and  one  third  or  one  half  of  the 
entire  organ. 

e.  The  state  of  the  tissues  varies.  Now  we  find  the  placenta  filled 
with  numerous  and  recent  clots;  now  their  number  has  diminished,  they 
are  decolorized  and  include  the  agglutinated  villi.  Again,  older  clots  are 
soft  and  their  centre  looks  like  broth,  varying  from  reddish-brown  to  yel- 
low, which  may,  according  to  Billroth,  be  true  pus,  which  is  denied  by 
Yirchow  and  Eobin. 

In  other  cases  the  coagula  are  stratified,  particularly  if  on  the  foetal 
surface.  The  tissue  may  be  so  hard  that  it  cannot  be  broken  up,  in 
which  case  it  is  of  a  dirty  white  or  gray.  The  vessels  in  the  diseased 
parts  are  generally  diminished  in  calibre  (Jacquemier),  but  they  are 
sometimes  obliterated  and  atrophied,  either  primarily  or  secondarily. 

The  microscopical  appearances,  according  to  Bustamente,  are  due  to 
changes  more  or  less  advanced  in  the  blood,  and  to  secondary  changes  in 
the  villi. 

A.  When  the  lesion  is  recent,  we  find  coagulated  blood  around  the  villi, 
and,  later,  fibrin  with  blood  corpuscles  in  its  meshes.  The  villi  in  the 
clot  are  intact,  but  their  vessels  are  filled  with  clotted  blood. 

B.  At  a  later  stage  the  fibrinous  meshes  are  closer  and  the  red  corpus- 
cles fewer,  and  so  changed  as  to  be  recognized  with  difficulty. 

The  white  corpuscles  change  to  connective  tissue  corpuscles,  and  the 
new  tissue  is  very  dense.  The  villi  undergo  fatty  degeneration.  The 
blood  in  the  vessels  becomes  granular,  and  the  connective  tissue  nuclei 
begin  to  proliferate.  Compound  granulation  corpuscles  appear  in  the 
clot.  At  the  most  advanced  stage  of  the  change,  the  white  corpuscles 
present  one,  two  or  three  nuclei.  Yellow  elastic  fibres  appear,  cross 
and  increase,  while  the  blood  corpuscles  disappear.     The  vessels  of  the 


DISEASES    OF   THE    OVUM.  233 

villi  become,  finally,  obliterated.  The  walls  of  some  of  the  villi  become 
fatty. 

The  mechanism  of  the  lesion  is  as  follows:  The  maternal  blood  current 
is  retarded  in  the  placental  sinnses,  the  blood  clots  surround  the  villi 
and  the  above  changes  occur.  According  as  the  coagulation  is  rapid  or 
slow,  the  coagula  are  amorphous  or  striated.  Bustamente  proposes  the 
name  placental  thrombosis  for  this  condition.  Cauwenberghe  says  that 
the  blood  undergoes  the  most  diverse  changes  in  different  jjarts  of  the 
same  or  of  different  placentc'e,  just  as  in  vascular  thrombi.  1.  The  decol- 
orized fibrin  may  remain  stratified  without  other  change;  2.  The  throm- 
bus is  transformed  into  connective  tissue;  3.  Ketrogressive  changes  occur 
in  the  blood,  the  red  corpuscles  disappearing  and  the  white  undergoing 
fatty  degeneration  and  being  carried  away.  The  fibrin  is  changed  to  a 
pulpy  mass  like  pus,  the  fibrinous  pseudo-pus  of  Eobin,  the  true  pus  of 
Billroth. 

The  microscope  presents  the  following  appearances  in  these  lesions: 

1.  Transformation  of  the  Blood. — In  some  cases  red  corpuscles  pre- 
dominate, in  some  the  fibrin.  The  white  corpuscles  may  be  few  and  scat- 
tered, or  grouped  and  in  layers.  The  red  corpuscles  become  deformed 
and  decolorized.  The  pigment  may  disappear  or  remain  a  long  time. 
At  this  time  the  fibrin  is  still  fibrillary  and  the  white  corpuscles  are  un- 
changed. Later,  the  red  corpuscles  break  up,  the  fibrin  becomes  gran- 
ular and  the  white  corpuscles  become  fatty  and  are  disintegrated.  When 
the  foci  do  not  enclose  villi,  the  clot  may  be  changed  to  pseudo-pus.  The 
fibrin  may  remain  unchanged.  But  may  the  clot  form  organized  connec- 
tive tissue?  This  is  admitted  by  Billroth,  Virchow,  Cohnheim  and 
Bustamente,  but  denied  by  Kobin,  Cauwenberghe  and  Maier.  Maier  says 
that  new  connective  tissue,  when  found,  is  the  result  of  hyperplasia  in  the 
decidua-serotina  or  interstitial  placentitis. 

2.  Cauwenberghe  considers  the  changes  in  the  villi  and  the  umbilical 
vessels  as  secondary,  and  repeats  Bustamente's  views,  but  he  agrees  with. 
Hegar  and  Maier  that  the  walls  of  the  large  vessels,  on  the  foetal  placental 
surface,  are  thickened  from  hypertrophy  of  the  tunica  adventitia,  the 
lumen  of  the  vessels  being  contracted  and  the  capillaries  empty. 

Ercolani,  1876,  considers  the  villi  to  be  formed  of  two  parts,  the  par- 
enchyma, (chorial  tissue  of  Eobin;  mucous  tissue  of  A'^irchow),  in  com- 
munication with  the  chorion  and  the  external  part  or  epithelial  envelope. 
He  distinguishes,  among  diseases  of  the  villi,  hypertrophy  or  myxoma 
of  Virchow;  hydatigenous  placenta;  myxoma  of  the  serotina  or  of  the 
glandular  organ  surrounding  the  villi.  The  first  two  lesions  correspond 
to  the  vesicular  mole  of  the  books.  Here  is  his  description  of  myxoma 
of  the  serotina:  The  placenta  belonged  to  an  abortive  fcetus  of  three  or 
four  months.  It  was  normal  and  completely  developed.  The  supposed 
placental  parenchyma  was  composed  of  an  intricate  net  of  villi,  between 


234  A    TREATISE    ON    OBSTETRICS. 

the  chorion  and  the  serotina.  The  microscope  showed  in  the  pedicles 
and  tufts  of  the  villi,  irregular  swellings  formed  by  a  layer  of  the  cells  of 
the  serotina.  In  the  cells  the  development  of  the  glandular  organ  was 
arrested  and  little  pediculated  bodies,  generally  pyriform,  had  appeared. 
Some  of  these,  Virchow's  physmlides,  contained  liquid  such  as  we  saw  in 
the  epithelial  proliferations  of  the  villi.  The  parenchyma  of  the  villi  had 
undergone  atrophy  and  fibroid  degeneration  at  the  beginning  of  its  devel- 
opment. 

Ercolani  considers  the  fibro-fatty  degeneration  of  the  placenta  a  cellular 
hypertrophy  of  the  parenchyma  of  the  foetal  villi,  simple  or  complicated 
by  vascular  obliteration  and  glandular  atrophy.  He  considers  the  hyper- 
plasia of  the  cells  in  the  mucous  tissue  of  the  villi,  to  be  peculiar  to  the 
disease. 

Dilatation  of  the  vessels  seems  to  be  the  result  of  the  obstacle  opposed 
to  the  circulation  by  obliteration  of  vessels  in  some  of  the  tufts  of  the 
villi.  The  reason  for  the  obliteration  is  the  pressure  exerted  on  the  ves- 
sels by  the  neighboring  cells,  which  are  greatly  increased  in  number  and 
in  volume.  The  volume  of  the  diseased  villi  is  augmented  and  they  form 
compact,  grayish  masses,  because  they  have  no  vessels  and  because  the 
maternal  blood  cannot  circulate  around  them.  This  is  the  lesion  des- 
cribed by  Bustamente  and  Neumann  as  sclerosis  of  the  placenta. 

Ercolani  also  describes  fibroma  of  the  villi  and  of  the  serotina.  Called 
fibro-fatty  degeneration  by  Eobin,  and  designated  as  syphilitic  by  VirchoM^ 
this  lesion  is  frequently  found,  according  to  Ercolani,  on  abortive  pla- 
centas expelled  after  the  third  month  or  on  placentas  at  term.  In  the 
latter  it  is  less  extensive.  In  the  beginning  of  the  transformation  of  the 
mucous  tissue  of  the  villi  into  fibrous  tissue,  the  cells  become  more  elliptical 
and  numerous,  and  the  surface  seems  firm  and  almost  vitreous,  Ercolani 
regards  this  really  as  a  hyaline  transformation  and  not  as  a  fibroid  one, 
because  amorphous  transparent  matter  abounds  in  the  cells. 

The  fibrous  transformation  is  now  partial,  now  general.  Obliteration 
of  the  vessels  in  the  villi  is  secondary.  The  fibrous  change  may  affect 
the  villi  alone,  or  also  involve  the  glandular  organ.  The  change  may 
occur  simultaneously  in  the  villi  and  the  serotina,  before  the  glandular 
organ  is  formed.  When  the  cells  of  the  serotina  assume  the  character 
of  fibrous  tissue,  they  remain  round  but  get  smaller,  arrange  themselves 
in  series,  lose  their  granules,  and  their  nucleus  is  rapidly  colored  red  with 
carmine. 

Later,  the  nyaline  substance  exudes  through  the  cell  walls,  and  the  cells, 
losing  their  round  form,  take  on  that  of  the  connective  tissue  corpuscles, 
having  numerous  inter-communicating  poles.  The  vessels  of  the  villi  are 
mostly  obliterated.  The  fibrous  tissue  of  the  serotina  is  fused  with  the 
new  fibrous  tissue  of  the  villi. 

Ercolani  and  Beiuzzi  also  mention  melanosis  of  the  placenta,  consisting 


DISEASES    OF    THE    OVUM.  235 

ill  the  deposition  of  pigment  granules  around  the  utero-placental  vessels 
or  in  the  villi.     The  pigment  is  hematoidin. 

Ercolani  states  that  there  may  be  thrombosis  of  the  sinuses  and  hem- 
orrhage. The  decidual  vessels  may  rupture  in  the  early  months,  and 
cause  hemorrhage  between  the  decidua  and  the  chorion.  The  chief  cause 
of  the  clots  and  hemorrhages  is  fatty  degeneration  of  the  cells  of  the 
serotina.  The  cells,  thus  altered,  support,  but  poorly,  the  pressure  of  the 
blood  in  the  lacunse,  and  hemorrhage  results.  He  has  never  observed 
the  transformation  of  the  coagula  into  pyoid  matter,  pus  or  neoplasms. 
He,  however,  remarks  that  the  diversity  of  color  in  apoplectic  centres, 
does  not  only  depend  on  the  time  and  character  of  the  changes,  but  also 
on  the  quantity  of  lacunal  blood  and  on  the  relative  rapidity  of  coagu- 
lation. 

Finally,  Duchamp,  in  1880,  returning  to  Robin's  view,  considers  fatty 
degeneration  secondary  to  fibrous  degeneration. 

From  an  examination  of  these  different  opinions  we  conclude  that  the 
subject  of  placental  lesions  may  be  summed  up  thus:  1.  Hemorrhages 
occur  in  the  placental  tissue,  and  the  extravasated  blood  undergoes  great 
change;  2.  The  villi  may  undergo  a  fibro-fatty  degeneration;  3.  There 
may  be,  simultaneously,  extravasation  and  degeneration  of  the  villi. 

But  the  questions  already  asked  by  us,  in  our  thesis  of  1869,  now  pres- 
ent themselves  again,  viz. :  1.  May  there  be  placental  hemorrhage  or 
thrombosis  without  change  in  the  villi?  2.  May  there,  conversely,  be 
changes  in  the  villi  without  hemorrhage  or  thrombosis?  3.  In  mixed 
cases,  with  both  lesions,  are  they  dependent  upon  each  other,  and  which 
is  the  initial  lesion  ? 

The  facts  reported  by  Hiffelsheim,  Laboulbene,  Depaul,  Ercolani  and 
de  Sinety  show  that  the  first  question  may  be  answered  affirmatively. 
The  same  is  true  of  the  second  question,  as  is  proved  by  the  cases  of  Eobin 
and  of  Depaul  and  de  Sinety. 

The  solution  of  the  third  problem  is  far  harder.  Less  positive  than 
formerly,  we  no  longer  say,  as  in  1869,  that  the  lesion  is  one.  There  is, 
first,  fatty  degeneration  and  obliteration  of  the  villi,  and  then  extravasation 
of  blood  which  undergoes  transformations;  these  two  lesions  being,  in 
reality,  successive  degrees  of  one  and  the  same  change  in  the  placenta. 
We  do  not,  however,  adopt  the  exaggerated  ideas  of  Bustamente.  His 
anatomical  considerations  on  the  structure  of  the  villi  are  not  conclusive. 
Indeed,  the  researches  of  the  Germans  and  of  Dastre  tend  to  show  that 
the  villus  is  not  hollow,  as  Eobin  thinks,  but  formed,  externally,  by  a 
layer  of  polyhedral  epithelial  cells  enclosing  fatty  globules  and  crystalline 
rings,  or  rods  beneath  this  layer,  and  by  a  parenchyma  of  connective  tis- 
sue arranged  in  planes  parallel  to  the  surface  and  forming  a  more  or  less 
dense  felt-like  tissue.  Stellate  cells  are  interposed  between  the  groups  of 
fibres.     The  villus  is  formed  by  a  displacement  of  the  chorion  when  the 


236  A    TREATISE    ON"    OBSTETRICS. 

vessels  enter,  but  no  central  canal  is  formed.  At  the  point  where  the 
displacement  of  the  chorion  is  to  occur,  the  fibres  of  connective  tissue, 
parallel  to  the  surface,  become  erect  to  enter  the  villi,  the  centre  of  which 
they  form. 

There  is,  here,  nothing  comparable  to  what  Oh.  Eobin  .understands  by 
the  fibrous  degeneration  of  the  villi,  which  is  a  well-ascertained  lesion. 
Besides,  if,  at  the  beginning  of  pregnancy,  the  extravasation  of  blood  can 
only  come  from  the  maternal  circulation,  it  may,  later,  come  from  the 
umbilical  vessels.  Millet  expressed  this  opinion  and  certain  microscopists 
have  seen  aneurisms  on  the  umbilical  vessels,  near  their  entrance  to  the  pla- 
centa, the  rupture  of  which  would  explain  the  apoplectic  extravasations. 
The  facts  quoted  by  Cauwenberghe,  himself,  and  by  Hegar  and  Maier  prove 
the  changes  in  the  umbilical  vessels.  We  reserve  our  decision,  for  both 
explanations  can  be  maintained  while  neither  is  absolutely  proven.  This 
is,  moreover,  Duchamp's  opinion. 

IV.   Calcareous  Changes  in  the  Villi. 

By  the  terms  ossification,  ossiform  concretions,  placental  calculi  and 
calcareous  degeneration,  authors  understand  deposits  of  lime,  either  on 
the  surface  or  in  the  interior  of  the  placenta.  Sometimes  there  are  iso- 
lated grains  or  needles,  sometimes  calcareous  masses.  The  grains  contain 
amorphous  carbonates  and  phosphates  of  lime  and  magnesia,  and  are 
found,  most  frequently,  on  the  uterine  placental  surface.  Carestia  has 
reported  some  on  the  foetal  surface.  Lobstein,  Meckel,  Adelon  and  Cru- 
veilhier,  thought  that  they  were  in  the  capillaries.  Eobin  has  shown  that 
the  grains  are  especially  found  in  the  cotyledons  whose  villi  are  wholly  or 
partly  obliterated.  They  adhere,  strongly,  to  the  surface  of  the  villi, 
surrounding  and  sometimes  obscuring  the  villi,  always  deforming  them. 
They  are,  then,  in  the  maternal  placenta,  as  Ercolani  also  believes. 

Etiology. — The  causes  of  the  changes  of  the  placenta  mostly  elude  us. 
Hegar  has  observed,  in  a  great  number  of  ova,  coexistent  anomalies  of 
the  decidua  and  of  the  embryo  which  we  have  mentioned  before,  and  this 
may  explain  the  abortions  occurring  in  the  first  months.  This  is  Hot 
true  of  the  important  placental  lesions  which  we  have  just  considered. 
The  advocates  of  the  theory  of  blood  changes  have  sought  the  explana- 
tion of  these  phenomena  in  placental  thrombosis.  But  what  are  the 
causes  of  this  thrombosis  ?  Cauwenberghe  finds  them  in  the  conditions  of 
the  placenta]  circulation,  the  modifications  of  which  seem  to  tend  to  one 
and  the  same  end,  viz.,  augmentation  of  the  quantity  of  blood,  and  ex- 
cessive slowing  of  the  circulatory  current,  or  changes  in  the  composition 
of  the  blood. 

Finally,  the  following  occasional  causes  ha  vet  been  noticed:  Extreme 
youth,  or,  on  the  contrary,  extreme  age;  the  predisposition  of  certain 
women  who  menstruate  very  abundantly;  acute  diseases  which  affect  the 


DISEASES    OF    THE    OVUM.  237 

circulation,  and  the  respiration;  the  eruptive  fevers;  pneumonia;  cholera; 
typhus;  the  diatheses  and  cachexias  (among  whicli  latter,  syphilis  is  the 
most  prominent),  and,  finally,  syncope,  gravido-ca  diac  troubles,  trauma- 
tisms, or,  in  one  word,  all  the  causes  of  abortion, 

1st.  Influence  upon  the  Mother. — All  authors  agree  that  whatever  the 
lesion,  it  exerts  no  influence  uj^on  the  mother.  The  sanguineous  effusions 
may  possibly,  it  is  true,  compromise  her  health,  and  exceptionally  endan- 
ger her  life;  but,  as  a  general  rule,  she  suffers  from  nothing  more  than  a 
more  or  less  pronounced  state  of  malaise,  which  has  only  a  passing  influ- 
ence upon  the  material  health.  According  as  the  disease  is  more  or  less 
intense,  and  according  as  it  has  or  has  not  accidental  complications,  thei 
mother  suffers  more  or  less;  but  the  placental  malady  seeme  to  have  hardly 
any  pathological  influence  upon  her. 

2d.  Influence  of  Placental  Lesions  upon  the  Foetus. — Here,  on  the  con- 
trary, all  authorities  agree  as  to  the  direct  influence  of  the  lesion.  How 
can  it  be  otherwise  ?  The  placenta  is  the  essential  organ  of  foetal  devel- 
opment; through  it  all  its  functions  of  nutrition  and  assimilation  are  ac- 
complished; through  it  it  respires  and  is  nourished,  and  from  it  draws 
the  elements  necessary  for  its  development.  Is  it  not  natural  that  the 
foetus  should  suffer  when  it  is  affected  with  disease  ?  We  may  con- 
clude with  Dubois:  "If  a  portion  of  the  placenta  still  preserves  its  struc- 
ture and  its  functions,  the  foetus  will  not  only  continue  to  live,  but  its 
nutrition  wall  suffer  little  or  nothing.  On  the  other  hand,  if  it  does  not 
die,  it  will  be  born  feeble,  thin,  and  wizened.  If  the  placental  disease  is 
progressive,  it  will  cause,  in  spite  of  our  efforts,  a  gradual  enfeeblement 
of  the  foetal  movements  and  heart-beats,  until  both  stop  completely;  and 
the  mother  and  the  accoucheur,  not  unfrequently,  help  on  the  agony  and 
death  of  the  foetus  in  these  unfortunate  cases." 

3d.  Influence  of  Diseases  of  the  Fwtus  tqjonthe  Placental  Lesion. — Is  it 
not  possible  for  the  state  of  health  or  the  life  or  death  of  the  foetus  to  react 
upon  the  disease  of  the  placenta  ?  We  are  entirely  dependent  upon  hypoth- 
esis for  an  answer.  It  is  true  that  placental  oedema,  atrophy,  and  hyper- 
trophy, appear  to  be  lesions  which  are  peculiarly  prone  to  follow  death  of  the 
foetus;  but  we  know  nothing  certain  about  it.  If  we  could  recognize  and 
diagnosticate  disease  in  the  foetus,  we  might  obtain  more  precise  data.  The 
only  thing  that  we  can  determine,  and  that  but  rarely,  is  the  condition  of  the 
heart-beat,  that  is  to  say,  the  life  or  death  of  the  foetus.  It  is  only  after  the 
beginning  of  the  second  half  of  pregnancy  that  even  this  is  possible, 
and  the  first  cause  of  the  death  of  the  foetus  escapes  us.  One  fact  only 
can  be  appreciated  at  the  time  of  the  death  of  the  foetus,  and  that  is  the 
almost  constant  tendency  to  abortion  which  follows  that  accident.  But 
how  often  do  we  not  see  this  accident  occur  without  there  being  either  in 
the  placenta,  the  membranes,  or  the  foetus,  anything  to  explain  the  death, 
and  we  are  forced  to  ascribe  it  to  general  causes,  to  diatheses.  Even  when 


238  A    TREATISE    OjST    OBSTETRICS. 

we  find  a  placental  lesion,  is  the  placenta  diseased  because  the  foetus  is 
dead?  or  has  the  foetus  died  because  the  plaoenta  is  abnormal?  The 
question  is  still  entirely  unanswered. 

John  Bremmer  has  studied  the  pathological  alterations  of  the  pla- 
centa, in  connection  with  their  influence  upon  the  course  of  labor.  He 
claims  that  placental  alterations  cause,  by  contiguity,  a  state  of  torpor  and 
debility  of  the  uterus,  which  manifests  itself  at  the  time  of  labor,  by  a 
more  or  less  marked  paralysis  of  the  organ.  Certain  symptoms  during 
pregnancy  enable  us  to  foretell  this  condition;  these  are  a  pale,  thin,  and 
pining  facies,  flaccid  breasts,  loss  of  flesh,  frequent  pains  in  the  back  and 
in  the  uterus,  but  above  all,  a  continuous  and  unbearable  state  of  malaise, 
lasting  day  and  night,  and  often  resisting  even  narcotics;  a  soft  or  com- 
pressible pulse,  and  a  slight  lowering  of  the  uterus.  At  the  time  of  labor, 
its  slowness  and  difficulty,  in  women  who  have  had  other  easy  deliveries, 
are  markedly  in  contrast  with  the  continuous  and  severe  pains,  and  soft- 
ness and  f acidity  of  the  os.  The  child  is  born  feeble  and  almost  asphyxi- ' 
ated,  or  it  may  be  covered  with  livid  blotches.  Others  again,  though 
born  at  term,  are  only  half  the. average  weight  of  new-born  infants;  they 
may  live  a  few  days. 

The  amount  of  alteration  m  the  placenta  does  not  appear  to  bear  any 
direct  relation  to  the  infant's  condition  as  regards  life  or  death. 

Finally,  the  escape  of  meconium,  if  not  always  a  sign  of  the  death  of 
the  foetus,  indicates  a  state  of  such  great  weakness  that  relaxation  of  the 
sphincters  has  occurred.  Nevertheless,  the  diagnosis  is  only  certain  after 
the  expulsion  of  the  placenta.  The  cord  looks  dirty,  and  the  vessels  are 
yellowish  green  in  color;  the  placenta  exhales  a  foetid  odor,  and  may  be 
smaller  than  usual,  but  its  texture  seems  to  be  but  little  changed. 

Hypertrophy. 

Hypertropliy  and  (Edema  of  the  Placenta. — These  two  lesions,  which 
are  inseparable,  are  due  to  an  increase  in  number  and  volume  of  the 
elements  constituting  the  villosities,  together  with  an  exudation  of  fluid 
material  between  these  elements.  The  epithelial  covering  remains  in- 
tact, though  it  is  hypertrophied  to  cover  the  enlarged  villi;  but  the  other 
structures  may  be  profoundly  modified.  The  cells  of  the  mucoid  tissue 
are  hyjoertrophied-  and  increased  in  number,  and  are  closely  aggregated 
together,  one  or  two  vessels  still  retaining  their  normal  calibre^  In  more 
advanced  degrees  of  change,  the  vessels  disappear  entirely  from  the  mu- 
coid tissue.  Within  the  epithelial  layer  are  a  large  number  of  round 
cells,  dentate,  and  with  fusiform  prolongations,  and  even  star-shaped;  in 
other  words,  we  find  a  true  myxoma  of  the  mucoid  tissue.  De  Sincty 
considers  this  the  first  stage  in  the  development  of  the  vesicular  mole. 
Ercolani,  as  we  have  seen,  regards  this  lesion  as  a  hyaline  transformation, 
because  few  cells  thus  changed  can  be  found  in  the  parenchyma  of  the 


DISEASES    OF   THE    OVUM.  231) 

villus,  while  the  amorphous  and  transparent  element  is  abundant;  and 
Wilde  lias  seen  the  trunks  that  were  not  dilated  by  fluid  undergo  a  fatty 
degeneration.  In  a  case  of  acute  hydramnion  in  a  twin  pregnancy,  de 
Sincty,  who  examined  the  placenta,  found  in  it  the  following  alterations: 
"Even  with  the  naked  eye  it  was  possible  to  distinguish  two  different  parts 
of  the  organ;  the  one  being  violet  red  and  filled  with  blood,  and  the 
other  looking  pale  yellow  and  thin.  The  fluid  appeared  to  be  everywhere 
between  the  membranes,  though  the  contents  of  the  amniotic  cavity  did 
not  seem  to  be  increased.  The  membranes  were  easily  detachable  from 
one  another.  Histological  examination  of  hardened  sections  showed  that 
the  red  portion  exhibited  a  considerable  dilatation  and  engorgement  of  the 
blood  spaces,  while  the  villosities  appeared  normal.  In  the  white  part, 
on  tl\e  other  hand,  the  walls  of  the  maternal  vessels  were  hypertrophied, 
and  there  was  no  blood  in  them.  The  villosities  had  but  few  vessels,  and 
they  were  bloodless.  There  were  seen  certain  dilatations  of  the  mucoid 
tissue  reticulum,  which  contained  an  amorphous  material  not  colorable 
by  either  picro-carminate  of  ammonia  or  by  purpurine. 

"  Some  of  these  spaces  contained  a  large  cell  which  almost  entirely  filled 
it.  In  most  villosities  of  the  white  portion  of  the  placenta,  the  cellular 
elements  were  much  more  numerous  than  is  normal.  Some  villosities 
had  become  fibrous,  or,  more  rarely,  fatty.  The  epithelial  covering 
Avas  notably  hypertrophied,  and  was  thus  much  more  apparent  than  in 
the  red  part.  The  cord  was  apparently  normal.  The  vein  and  one  of 
the  arteries  contained  blood-cells;  but  the  other  artery  was  contracted, 
and  almost  obliterated,  and  contained  no  blood;  it  only  had  a  few  small 
round  elements,  which  were  colorable  by  reagents,  and  appeared  to  be  due 
to  endothelial  proliferation.  The  intima  was  infiltrated  with  these  same 
elements,  showing  the  existence  of  endarteritis.  In  the  healthy  artery  we 
could  see,  in  the  midst  of  the  blood  globules,  acertainnumber  of  giant  cells 
of  various  shapes.  They  appeared  also  in  the  vein,  but  less  abundantly, 
and  mostly  rounded.  The  stroma  of  the  cord  and  its  covering  were  nor- 
mal. In  short,  the  lesion  consisted  of  a  partial  oedema  of  the  placenta, 
together  Avith  complete  angemia  of  that  region,  probably  of  maternal 
origin.  Although  I  do  not  consider  the  lesion  a  specific  one,  I  must  add 
that  I  have  seen  similar  lesions  in  cases  of  syphilitic  placenta."  There  was 
no  syphilis  in  either  the  patient  or  her  husband. 

Atrophy  of  the  Placenta. 

This  lesion  has  been  attributed  by  various  authors  to  hemorrhages,  to 
fatty  degeneration,  or  to  consecutive  blood  changes.  It  may  be  partial 
or  general.  But  atrophy  does  not  always  appear  to  be  due  to  the  above 
causes,  since  placentse  have  been  found  whose  dimensions  are  much  re- 
duced, though  the  tissue  of  the  organ  itself  shows  nothing  |)eculiar.  This 
is  an  anomaly,  and  if  very  pronounced,  may  interfere  with  foetal  nutri- 


240  A    TREATISE    ON"    OBSTETRICS. 

tion^  though  not  to  the  extent  that  it  does  in  cases  of  consecutive  atrophy, 
involving  the  v^^hole  or  a  great  portion  of  the  placenta. 

Sclerosis  of  the  Placekta. 

This,  according  to  Bustamente,  causes  the  placenta  to  appear  as  a  red- 
dish, flesh-like,  lobulated,-  and  smooth  mass,  bearing  some  resemblance  to 
the  thymus  gland.  It  is  homogeneous  and  dense  to  the  cut.  The  altered 
portion  adheres  partly  to  the  villosities  of  the  healthy  part.  Towards  the 
sides,  and  especially  upon  the  foetal  face  of  the  placenta,  the  normal  tis- 
sue is  encroached  upon  and  compressed;  as  may  easily  be  seen  if  the 
altered  portions  be  removed.  The  mucous  coat,  on  the  uterine  portion  of 
the  placenta,  is  detachable  over  the  abnormal  parts. 

On  microscopic  examination,  the  villosities  of  the  morbid  tissue  are  not 
well  defined.  The  section  is  homogeneous,  and  shows  very  small  arterial 
vessels  at  the  centre  of  the  lobules.  It  is  composed  of  fibro-plastic  ele- 
ments arranged  in  regular  order  m  concentric  layers,  almost  like  the  vas- 
cular tissues. 

Cysts  of  the  Placenta. 

According  to  Millet,  who  has  seen  two  cases,  the  walls  of  placental  cysts 
are  formed  of  layers  of  tissue  very  like  that  which  we  find  interposed  be- 
tween the  chorion  and  the  amnion.  The  fluid  they  contain  resembles, 
both  in  consistence  and  in  composition,  the  gelatine  of  Wharton.  The 
cyst  is,  in  fact,  developed  in  rneshes  of  the  cellular  tissue,  just  as  are  those 
cysts  of  the  cord  which  Euysch  has  described  under  the  name  of  hyda- 
tidiform  degeneration  of  the  umbilical  cord. 

Bustamente  describes  a  kind  of  cyst  which  is  sometimes  found  upon  the 
foetal  surface  of  the  placenta,  of  a  regularly  rounded  or  elongated  shape, 
and  varying  in  size  from  |  of  an  inch  to  2  or  2f  inches.  They  are  placed 
below  the  amnion  and  chorion,  which  form  their  superficial  or  foetal  boun- 
dary, being  limited  below  by  the  placental  tissue  itself. 

The  contents  of  these  cysts  are  solid  and  liquid.  The  fluid  is  usually 
lemon-colored,  lactescent,  and  contains  blood  globules.  Nitrate  of  silver 
causes  a  curdy  precipitate;  heat  and  nitric  acid  show  the  presence  of  al- 
bumin. Underneath  this  liquid  portion  of  the  contents  is  a  whitish  or 
.slightly  yellow  substance,  from  ^  of  an  inch  to  f  of  an  inch  in  thickness. 
Under  the  microscope,  this  tissue  is  seen  to  consist  of  reticulated  fibrin, 
perhaps  containing  in  its  meshes  some  placental  villi.  Close  inspection 
reveals  the  fact  that  it  is  disposed  in  layers.  The  greas}  masses  of  which 
it  is  apparently  composed,  are  usually  found  towards  the  centre  of  the 
placenta,  in  the  intervals  between  the  large  vessels.  Finally,  it  is  not 
unusual  to  find  plates  on  the  surface  in  which  we  find  a  small  quantity 
of  fluid,  having  the  same  characters  as  the  liquid  of  the  cysts. 

How  are  these  cysts  formed  ?     A  coagulation  has  taken  place  against 


DISEASES    OF    THE    OVUM.  241 

tlie  chorion,  forming  the  plate  which  is  the  deeper  layer  of  the  cyst.  The 
fluid  may  be  produced  in  one  of  several  ways:  1st.  A  certain  quantity  61 
blood  may  have  been  included  between  the  coagulum  and  the  chorion; 
or  the  blood  may  iiave  appeared  later,  after  the  formation  of  the  first 
layers  of  the  plaque,  from  rupture  of  the  layers.  2d.  Or  a  little  bleeding 
point  may  be  left  open,  and  the  blood  then  tears  a  cavity  between  the 
chorion  and  the  plaque  of  coagulated  fibrin.  We  cannot  attribute  these 
to  the  rupture  of  a  vessel,  since  in  the  cases  examined  there  was  no  such 
thing.  The  fibrinous  parietal  layer  also  shows  evidence  of  having  come 
from  the  maternal  blood  of  the  j)lacenta. 

Ercolani  has  seen  two  cases  of  placental  cyst.  In  one  the  entire  foetal 
surface  of  the  placenta  was  sown  with  round  tumors,  covered  by  the  cho- 
rion, the  largest  being  about  the  size  of  a  cherry.  Some  had  been  opened, 
and  the  chorional  wall  torn,  showing  a  solid  material  filling  the  depths 
of  the  cyst.  They  were  in  fact  like  the  variety  described  by  Bustamente. 
Others  again  were  more  solid,  and  were  filled  with  coagulated  fibrin,  in* 
which  rounded  masses  of  granular  hsematin  could  be  seen. 

In  the  second  case  three  hemorrhagic  centres  could  be  easily  distin- 
guished upon  the  fcetal  surface;  they  were  round,  red  in  color,  and  about 
the  size  of  small  peas.  Others  were  less  prominent  and  more  irregular 
in  shape.  In  those  that  were  cyst-like,  Ercolani  proved  that  the  interior 
wall  was  formed  by  the  chorion,  which  covered  the  whole  bloody  mass, 
of  which  half  projected  above  the  placental  surface,  while  half  dipped 
into  the  placental  tissue,  and  lay  in  immediate  contact  with  the  effused 
blood.  The  term  cyst  is  therefore  inexact.  At  the  placental  depths  of 
these  tumors,  the  villosities,  more  fibrous  than  usual,  formed  a  compact 
layer,  certain  spots  in  which  turned  out  to  be  cells  of  the  serotina,  some 
of  which  plainly  showed  fatty  degeneration  of  the  nuclei.  Small  irregular 
calcareous  concretions  were  scattered  through  the  mass. 

TUMOKS   OF   THE    PLACENTA. 

The  following  is  the  description,  by  A.  Danyau,  of  a  tumor  occurring  in 
a  healthy  woman,  and  after  a  normal  pregnancy,  the  only  effect  of  the 
mass  being  to  cause  considerable  abdominal  distension,  so  that  labor  oc- 
curred at  the  seventh  month.  "  Near  the  margin  of  the  fcetal  portion  of 
the  placenta,  is  an  oval  tumor  4f  inches  long  by  3-|-  inches  broad,  and 
covered  by  the  membranes,  which  are  partly  detached  from  its  surface. 
Several  large  venous  and  arterial  branches  of  the  umbilical  vessels  run 
over  its  surface  and  penetrate  its  substance  to  the  centre.  The  tumor  is 
lobulated,  and,  besides  the  membranes,  has  a  proper  envelope,  thin  super- 
ficially, thicker  over  the  portion  covered  by  placenta,  easily  torn,  and  ap- 
parently formed  of  plastic  lymph  more  or  less  condensed.  Divided  longi- 
tudinally, the  tumor  appears  to  be  composed  of  intimately  adherent  lobes, 
some  being  of  a  dead  white,  and  others  of  a  pale  or  deep  rose  tint;  its 
Vol.  it.— 16 


242  A   TREATISE    ON    OBSTETRICS. 

tissue  is  homogeneous,  very  dry,  like  seliirrhus  in  appearance,  and  crying 
under  the  scalpel;  its  color  and  consistence  reminding  one  in  some  places 
of  the  cortical  substance  of  the  kidney,  and  appearing  in  others  to  be  com- 
posed of  layers  of  fibrin;  vascular  orifices  are  apparent,  some  of  which 
are  still  filled  with  clots." 

The  author  describes  a  second  similar  but  smaller  tumor,  and  adds, 
that  the  portion  of  the  placenta  upon  which  they  rest  is  depressed;  that 
the  tumors  can  be  nucleated;  that  the  placental  tissue  is  then  very  com- 
pact, and  that  a  neighboring  cotyledon  contained  a  blood  clot  about  the 
size  of  a  filbert.  The  second  tumor  was  observed  under  circumstances 
similar  to  the  rest;  it  differed  only  by  a  greater  homogeneity  of  the  tis- 
sue out  of  which  it  was  formed,  and  by  the  absence  of  the  layer  of  plastic 
lymph  which  almost  entirely  covered  the  first  one. 

The  author  then  discusses  the  nature  of  these  tumors,  whether  they 
are  monstrosities  or  moles,  or  perhaps  due  to  degeneration  of  the  decidua, 
or  whether  of  cancerous  nature.  Danyau  comes  to  what  appears  to  us 
the  well-founded  conclusion,  that  they  are  due  to  anterior  sanguineous 
effusions.  In  conclusion,  he  states  that  the  tumors  appeared  to  have  no 
evil  influence  upon  either  pregnancy,  delivery  or  the  puerperal  state,  and 
that  they  cannot,  at  present,  be  diagnosticated  before  birth. 

Syphilitic  Lesions  of  the  Placekta. 

It  is  only  recently  that  syphilitic  affections  of  the  placenta  have  been 
studied.  Duchamp  has  given  the  best  resume  of  the  subject.  He  shows 
that  while  Astruc,  in  1796,  recognized  abortion  as  a  consequence  of  syph- 
ilis, Murat  first,  in  1820,  noticed  certain  black  spots  upon  the  organ,  due 
to  hemorrhage,  though  Paul  Dubois,  Putegnat,  and  d'Outrepont  denied 
their  significance.  Simpson  and  Lebert,  in  1822,  Virchow,  Barensprung, 
Wilk,  Biervliet,  Slavjansky,  Kleinwachter,  Mayer,  Adamson,  Birne,  Ver- 
dier,  Hennig,  and  ourselves,  have  noticed  these  lesions  in  the  placentas 
of  syphilitic  children.  Frankel,  in  concert  with  Waldeyer  and  Kolaczek, 
was,  however,  the  first  to  bestow  serious  attention  on  the  subject. 

He  could  collect  fifteen  observations  of  syphilis  transmitted  from  the 
father,  in  which  nothing  more  than  hypertrophy  of  the  villi  could  be 
found;  but  when  the  mothers  were  diseased,  the  lesions  were  more  com- 
l^lex.     His  conclusions  were  as  follows: 

1st.   There  is  a  syphilitic  placenta,  with  characteristic  features. 

2d.   It  is  only  found  in  cases  of  congenital  or  hereditary  foetal  syphilis. 

3d.  The  seat  of  the  lesion  is  different  when  the  mother  is  affected,  or 
when  the  virus  is  simply  transported  by  the  zoosperm  to  the  egg. 

a.  In  the  latter  case  the  placenta  is  degenerated  and  the  foetus  is  dis- 
eased, and  the  villi  of  the  foetal  placenta  are  filled  with  fatty  granulations; 
their  vessels  are  obliterated,  and  their  epithelial  coverings  thickened  or 
absent. 


DISEASES    OF    THE    OVU.M.  243 

h.  The  mother  being  infected,  one  of  three  conditions  may  be  present: 

1.  If  the  mother  is  infected  during  tlie  generative  act,  at  the  same 
time  as  the  foetus,  syphilitic  foci  will  often  develop  in  the  maternal  pla- 
centa (placental  endometritis.) 

2.  If  the  mother  is  syphilitic  before  conception,  or  becomes  so  shortly 
after,  the  chances  of  the  placenta  remaining  healthy  are  about  even.  In 
the  latter  cases  the  endometritis  gummosa  of  Virchow  is  observed. 

3.  If  the  mother  is  not  infected  until  after  the  seventh  month  of  preg- 
nancy, both  foetus  and  placenta  escape  entirely. 

4.  Infection  of  the  fQ3tus  during  delivery  has  not  been  proved. 
Macdonald,  in  1875,  noticed  hyperplasia  of  the  villi  in  cases  of  paternal 

origin.  The  vessels  are  especially  affected,  and  there  is  considerable  peri- 
vascular hyperplasia,  followed  by  vascular  atrophy  and  disappearances  of 
the  villous  tissue.  The  rest  of  the  placenta  is  the  seat  of  congestions  and 
bloody  effusions.  In  cases  of  maternal  origin  there  is  hyperplasia  of  the 
elements  of  the  decidua,  with  compression  and  atrophy  of  the  villi — in 
fact,  the  endometritis  of  Virchow  and  of  Slavjansky. 

When  both  mother  and  father  are  syphilitic,  the  lesions  are  mixed. 
Nevertheless,  Tarnier  and  Depaul  doubt  the  existence  of  specific  lesions 
of  the  placenta.  De  Sinety,  if  .he  has  not  found  lesions  in  every  case,  has 
proved  that  the  following  three  important  changes  may  occur. 

1.  Hypertrophy  of  the  villi,  which  may  be  doubled,  or  even  tripled  in 
size. 

2.  Fibroid  degeneration  of  the  villi. 

3.  Nodules  of  cheesy-degenerated  granulations. 

The  coincidence  of  the  fibroid  and  caseous  degenerations  is  found  in 
syphilitic  gummata,  and  notably  in  those  of  the  liver,  and  although  de 
Sinety  has  not  found  this  ensemble  of  lesions  in  any  other  disease  than 
syphilis,  he  does  not  enter  upon  the  question  of  the  specific  nature  of  the 
lesion;  he  does  not  deny  that  a  disease  other  than  the  pox  may  cause  them, 
but  he  suspects  syphilis  when  he  finds  all  three  lesions.  In  two  cases  his 
surmises  have  been  clinically  confirmed.      (Duchamp.) 

Albuminuric  Chaisj-ges. 

Chantreuil  has  found,  m  a  certain  number  of  albuminuric  women,  pla- 
cental lesions  consisting  of  whitish  plaques,  some  of  Avhich  the  micro- 
scope showed  to  be  tissue  in  a  state  of  fibro-fatty  degeneration.  Others 
again  were  merely  collections  of  fibrin.  They  were  fatty  degenerations  of 
the  placental  villi,  and  apoplexies.  There  was  a  placentitis  albuminurica, 
analogous  to  the  retinitis  albuminurica. 

ADHESIO]srS   OF   THE    PlACENTA. 

The  two  most  complete  works  upon  this  subject  are  those  of  Van  Lyn- 
seele,  and  of  Hegar.     The  latter  found  adhesions  in  cases  of  abortion,  of 


244  A   TREATISE    ON   OBSTETRICS. 

premature  /abor,  and  of  delivery  at  term,  and  showed  them  to  be  due  to 
such  pathological  processes  as  degeneration  of  or  hemorrhage  into  the  pla- 
centa, and  inflammations  of  its  parenchyma,  of  the  decidua,  and  of  the 
tissues  about  the  uterus. 

1st.  In  cases  of  abortion  and  premature  labor  there  is  an  arrest  in  the 
process  of  involution  of  the  placenta.  Eetention  of  the  placenta  occurs 
from  the  intimate  union  between  the  maternal  placenta  and  the  uterine 
parietes,  from  separation  of  the  maternal  from  the  foetal  placenta,  from 
the  want  of  energy  in  the  uterine  contractions  due  to  incomplete  develop- 
ment of  the  muscular  layer,  from  the  resistance  of  the  cervix,  and  from 
pathological  processes  of  the  uterus,  of  the  appendages  of  the  egg,  and 
of  the  organs  in  the  neighborhood  of  the  womb. 

2d.  In  cases  of  vesicular  mole,  to  which  we  shall  presently  return. 

3d.  In  case  of  exudative  processes,  and  of  extravasations  into  the  pla- 
centa. 

That  adhesions  from  primary  exudations  from  the  uterine  wall  do  occur, 
has  been  anatomically  demonstrated.  (Obs:  of  Stradfort,  Chiari,  Clay, 
Braiin,  Wrisberg,  Hegar,  Simpson,  Meckel,  Hiiter,  Siebold,  Stoltz).  The 
placental  tissue  may  appear  solid,  anaemic,  and  white,  or,  on  the  contrary, 
it  may  be  soft,  friable,  and  brownish,  but  it  is  firmly  attached  to  the 
uterus  by  the  uniting  layer.  Thus  the  placenta  is  easily  torn,  and  frag- 
ments remain  in  the  uterus  at  the  time  of  delivery. 

Some  authors  have  described  adherent  placentas  in  a  condition  of 
atrophy;  they  were  dry,  small,  and  anaemic. 

When  the  adhesions  are  secondary,  they  occur  in  consequence  of  exu- 
dations and  extravasations  into  the  parenchyma  of  the  placenta,  or  be- 
tween it  and  its  membranous  covering.  The  uniting  layer  of  the  mucosa 
participates  in  the  lesion  by  extension  of  the  morbid  process,  by  the  irri- 
tation which  the  pathological  product  causes  in  its  vicinity,  and  by  the 
modifications  of  the  circulation  which  it  effects.  The  effusions  poured  out 
between  the  membranous  coverings  and  the  foetal  surface  of  the  pla- 
centa most  often  extend  to  the  periphery,  following  the  ramifications  of 
the  umbilical  vessels  along  the  external  surface  of  the  chorion,  and  with 
prolongations  extending  to  the  decidua. 

These  placental  adhesions  may  be  spread  out  as  membranes  or  may 
form  bands  and  cords.  They  rarely  extend  over  the  entire  uterine  sur- 
face. 

Causes. — These  may  be  diseases  of  the  foetus,  of  the  umbilical  vessels, 
of  the  amnion,  or  of  the  chorion;  or  they  may  be  obstacles  to  the  umbi- 
lical circulation,  hemorrhages  and  effusions,  or  endometritis. 

Hegar  believes  that  he  can  recognize  them  during  pregnancy,  but  the 
symptoms  that  he  gives  are  of  very  doubtful  value. 


DISEASES   OF    THE    OVUM. 


245 


Moles. 

Mole  was  the  name  formerly  given  to  tlie  fibrinous  masses  -which  women 
sometimes  pass  during  menstruation,  and  also  to  the  altered  products  of 
abortion.  Hence  the  distinction  between  true  moles  and  false  moles, 
which  were  further  classified  according  to  their  appearance  as  fleshy,  ves- 
icular, and  watery  moles.  Now-a-days,  under  the  name  of  the  hydatid  or 
vesicular  mole,  or  the  designations  of  cystic  degeneration  of  the  chorion 
and  the  placenta,  dropsy  of  the  chorional  villi,  myxoma  of  the  placenta, 
all  authors  describe  a  peculiar  placental  alteration,  characterized  by  the 
production  of  more  or  less  pedunculated  vesicles,  and  sometimes  forming 
a  very  considerable  mass. 

Madame  Boivin  distinguishes  four  kinds  of  moles:  1st.  The  red,  fleshy, 
and  vascular  mole,  due  to  abnormality  of  the  sanguineous  system  of  the 
embryo.  2d.  The  white,  hydatid  or  vesicular  mole,  due  to  lesions  of  the 
membranous  shell  of  the  egg.  3d.  The  complex,  fleshy  and  vesicular  mole, 
due  to  lesions  of  both  portions.  4th.  The  embryonal  mole,  composed  of 
an  embryo  and  a  mole,  due  to  the  partial  degeneration  of  one  germ,  and 
the  complete  degeneration  of  another. 

Madame  Boivin  insists  that  the  vesicular  mole  is  always  the  product  of 
sexual  intercourse,  and  states  in  proof  thereof,  that  its  enveloping  mem- 
brane is  entirely  analogous  to  the  epichorion  or  decidua.  This  enveloping 
membrane  is  sometimes  expelled  entire  with  its  hydatid  contents,  and  it 
is,  like  the  decidua,  the  bond  of  communication  between  the  body  which 
it  encloses  and  the  matrix  to  which  it  adheres. 

If  the  decidua  is  adherent,  it  may  not  be  expelled  with  the  vesicular 
mass;  it  may  putrefy  and  exfoliate  and  gradually  break  down  and  flow 
away,  exactly  as  occurs  after  ordinary  delivery. 


Time  of  the  First  Hemorrhage,  and  its  Duration  in  Hydatid  Gestation. 


Names  of  Authors. 

Time  of  first 
hemorrhage. 

Time  of 
delivery. 

Duration 
of  flow. 

Dumanceau,    . 

at  45  days. 

at 

8  months. 

6i  months. 

Mme.  Boivin,  . 

a 

45 

(( 

4 

H     " 

Littre,     . 

"• 

2  months. 

6 

4 

Crawfort, 

a 

3 

a 

7 

4 

Souville, 

(I 

3 

i  i 

7 

4 

Percy, 

a 

3 

a 

8 

5 

Mme.  Boivin,  . 

a 

H 

ii 

8 

4^       - 

Pichart, 

a 

4 

a 

4 

Millot,     . 

a 

4 

i( 

4 

Delamotte, 

a 

5 

a 

H 

15  days. 

Percy 

a 

6 

a 

9 

3  months. 

Bremser, 

a 

7 

"■ 

8 

1  month. 

Jolly,      .         .         . 

a 

8 

a 

10 

2  months. 

Baudelocque,  . 

a 

11 

i< 

11 

ei 

a 

16 

i< 

14 

246 


A    TREATISE    ON    OBSTETRICS. 


Duration  of  Hydatid  Gtestation. 

Observations  in  28  Cases. 


Woman  delivered  at  14  months, 
11 
10 


1 

case. 

1 

a 

3 

cases. 

3 

" 

4 

a 

1 

case. 

1 

i< 

5 

cases. 

2 

( ( 

3 

a 

4 

i  i 

28 

cases. 

7         ' '     and  8  days 

7 

6 

5i 

4 

3 


Dubois  and  Desormeaux  describe  tbree  varieties  of  hydatid  mole:  1st. 
The  embryonal  hydatid  mole.  2d.  The  hollow  hydatid  mole.  3d.  The 
hydatid  mole  e7i  masse. 

The  first  variety  consists  of  a  membrane,  vesicular  on  its  outer  surface, 
with  an  internal  cavity  containing  a  foetus  or  parts  of  one,  and  possibly 
fluid. 

The  second  kind  is  like  the  first,  save  that  its  cavity  contains  only  fluid, 
and  possibly  a  remnant  of  the  umbilical  cord,  the  fcetus  having  been  dis- 
solved. 

The  third  variety  is  distinguished  by  the  enormous  development  of  the 
hydatid  bodies,  and  the  more  or  less  complete  etfacement  of  the  central 
cavity  formed  by  the  amnion,  the  place  of  which  is  taken  by  a  mass  of 
soft,  yellowish,  spongy  tissue. 

Moles  of  all  kinds  are  covered  by  a  thick  membrane,  which  is  in  imme- 
diate contact  with  the  uterus,  and  which  is  nothing  but  the  decidua. 

Cayla  has  sought  to  prove  that  the  hydatid  moles  are  only  uterine  vil- 
losities,  modified  in  shape  and  size  by  the  accumulation  of  fluid  within 
their  cavities.  He  thus  describes  what  he  calls  dropsy  of  the  chorional 
villi.  "  The  pedicle  of  the  villus  forms  a  membranous  tube  filled  with 
serosity,  and  some  -J  to  one  inch  in  length.  At  the  point  where  the  pedi- 
cle begins  to  branch,  the  dilatations  or  hydatid  vesicles  begin  to  develop. 
They  may  be  as  large  as  a  hazel-nut,  or  so  small  as  to  be  hardly  visible, 
smaller  vesicles  often  springing  by  a  short  pedicle  from  the  larger  ones; 
the  pedicle  being  the  non-dilated  portion  of  the  branch.  The  flow  of 
fluid  is  free  from  one  vesicle  into  another.  Curious  groups  of  vesicles 
of  varying  size  and  shape  are  thus  formed.  Each  vesicle  is  oval,  spheri- 
cal or  pear-shaped.  Occasionally  one  will  be  found  triangular,  or  even 
cylindrical  in  shape.  A  few  are  more  irregular,  and  have  prolongations 
in  various  directions.  The  microscope  shows  small  cysts  upon  the  pedi- 
cles or  on  the  walls  of  the  vesicles;  these  are  vesicles  in  process  of  forma- 
tion. 


DISEASES    OF   THE    OYUJI. 


247 


''Texture  of  Vie  Hydatid  Bundles. — They  are  usually  easily  isolated, 
though  they  may  be  more  or  less  intimately  interlaced,  when  they  form  a 
mass  of  cysts  as  thick  as  the  placenta,  in  the  centre  of  which  nearly  nor- 
mal villi  may  be  found. 

"Contents  of  the  Vesicles. — The  walls  are  thin,  semi-transparent  and 
resisting.  The  contents  consist  of  a  transparent,  reddish,  serous  fluid, 
albuminous  and  coagulable  by  alcohol  and  nitric  acid.  There  is  no  trace 
of  cysticerci  or  echinococci. 


Fig.  22.— Hydatid  Mole.— This  mass,  whlcli  weighed  2  pounds  2  ounces,  preserved  the  shape  of 
the  uterine  cavity  in  which  it  was  enclosed.  On  opening  it,  a  certain  quantity  of  the  hydatid 
vesicles  that  it  contained  escaped.  Two  membranous  layers  could  be  distinguished;  the  first,  a,  the 
external  or  uterine  membrane,  analogous  to  the  epichorion  or  decidua;  the  second,  6,  thin  and 
transparent  and  apparently  consisting  of  the  remains  of  the  chorion,  c.c.c.  Granular  vesicles,  d. 
Free  vesicles,    e.e,  Oblong  vesicles.    /./,  bud-like  vesicles.    (Mme.  Boivin.) 


"  Two  yarieties  of  special  cells  were  found  in  equal  and  limited  numbers 
in  this  fluid. 

"The  first  are  spherical,  transparent  and  regular  with  one  or  two  round 
nuclei,  and  contain  fine  gray  molecular  granulations.  The  nuclei  con- 
tain a  small  brilliant  nucleolus.  They  are  unlike  any  known  anatomi- 
cal element. 

''  The  second  yariety  belongs  to  the  class  of  payement  epithelium  and 


248  A    TREATISE    ON    OBSTETRICS. 

are  exactly  like  the  cells  of  that  tissue  save  for  the  brilliant,  yellowish, 
molecular  granulations  that  they  contain.  It  is  diflScult  to  understand 
the  origin  of  these  cells  if  we  admit  that  the  cysts  were  formed  after  the 
penetration  of  the  vessels;  for  there  is  no  pavement  epithelium  in  capil- 
laries. 

"  The  walls  of  the  vesicles  are  formed  by  the  chorional  tissue.  They 
contain  a  large  number  of  brilliant  molecular  granules,  or  sometimes,  in- 
stead of  that,  very  fine  grayish  grains.  Thus  the  hydatid  vesicles  are 
nothing  but  dilatations  of  the  chorional  villi." 

We  have  seen  that  the  dropsy  may  occur  when  the  placenta  is  com- 
pletely organized,  but  that  it  may  take  place  much  earlier  is  shown  by  the 
isolated  vesicles,  and  by  the  examples  of  eggs  expelled  entire,  whose 
whole  chorional  surface  was  covered  with  groups  of  vesicles,  proving  that 
the  alteration  occurred  at  a  time  when  the  chorion  was  entirely  villous. 

Clots  of  varying  consistency  and  color  are  almost  invariably  found  in 
the  midst  of  the  vesicular  mass,  which  may  explain  the  coloration  of  the 
vesicles.  Amnion  and  chorion  showed  no  lesion.  The  weight  varies, 
and  may  reach  eleven  pounds. 

Depaul,  accepting  the  division  of  Dubois  and  Desormeaux,  seeks  to  ex- 
plain the  nature  and  occurrence  of  the  various  elements  encountered  in 
the  vesicles  thus: 

"  The  vesicular  liquid  is,  at  first,  transparent,  and  any  reddish  tinge  is 
due  to  blood  temporarily  in  contact  with  the  vesicles,  the  hsematin  of 
which  has  been  dissolved  and  has  reached  the  fiuid,  for  Eobin  found  no 
blood  globules  in  the  fluid  he  examined.  The  rupture  of  the  allantoic 
vessels,  then,  causes  the  color.  We  do  not  know  where  the  epithelial 
cells  come  from  any  more  than  we  know  the  real  cause  of  the  dropsy  of 
the  villi. 

' '  What  are  the  causes  of  the  differences  observed  in  the  various  hydatid 
moles  ? 

"In  the  first  place,  the  membranous  envelop  of  the  mole  must  be 
the  decidua.  Each  vesicle,  like  the  chorional  villus  from  which  it  has 
sprung,  is  in  intimate  relationship  with  the  internal  surface  of  this  mem- 
brane. 

"  The  dropsy  always  begins  early  in  embryonal  life.  If  it  occurs  at  the 
very  beginning,  the  villosities  which  cover  the  entire  surface  of  the  egg 
will  undergo  hydatidiform  degeneration.  The  embryo  and  its  membranes 
will  be  dissolved,  and  we  will  have  the  mole  e7i  masse  of  Desormeaux  aad 
Dubois. 

"If  it  occur  later,  the  amniotic  cavity  will  persist,  though  the  foetus 
will  be  dissolved,  and  we  will  have  the  mole  hollow. 

"As  to  the  third  form,  the  embryonal  mole,  the  dropsy  also  dates  from 
the  first  period  of  embryonal  life,  but  a  portion  only  of  the  villi  are  in- 
volved, being  those  which  were  nearest  to  the  inter-utero-placental  de- 


DISEASES    OF    THE   OVUM.  249 

cidna.     The  allantoic  vessels  in  the  other  villi  sufficed  to  maintain  the  life 
of  the  embryo;  when  they  became  involved,  death  of  the  foetus  ensued." 

Though  the  arrangement  in  clusters  of  Cayla  is  evident  in  quite  a  num- 
ber of  cases,  it  cannot  always  be  demonstrated,  on  account  of  the  fre- 
quently intricate  interlacement  of  the  villi,  even  in  the  normal  state. 
Cruveilhier,  therefore,  has  given  a  somewhat  different  description  of  the 
mole.  He  claims  that  the  vesicles  are  not  bunched,  and  are  not  united 
by  a  common  pedicle,  but  that  they  are  joined  to  one  another  by  num- 
bers of  delicate  filaments. 

Ancelet  has  observed  the  same  thing,  and  describes  two  forms  of  ad- 
herence for  the  vesicles,  one  by  a  pedicle,  and  the  other  by  filaments. 
The  pedicle,  whose  diameter  is  greater  the  less  the  vesicle  is  developed, 
represents  a  simple  circular  contraction,  and  is  formed  by  the  more  or  less 
intimate  fusion  of  the  internal  membrane  of  two  adjacent  vesicles. 

The  adhesion  diminishes  as  the  vesicles  develop,  and  they  assume  a 
pyrif  or m  shape;  then,  as  they  tend  to  detach  themselves,  their  fibro-cellular 
pedicle  finally  breaks. 

Do  the  vesicles  communicate  with  each  other  ?  Vallisnieri  and  Cayla, 
and  especially  Shrokius,  who  insufflated  them,  say  they  do;  Madame  Boi- 
vin  is  doubtful;  Ancelet  could  not  prove  it.  As  to  their  structure,  Cru- 
veilhier says  that  the  cyst  membrane  is  composed  of  a  single  layer  of 
transparent  reticulated  tissue;  Pelvet  has  always  found  it  formed  of  mole- 
cular granules;  while  Luys  claims  that  it  is  fibroid  and  non-vascular. 

From  these  various  opinions  Ancelet  concludes:  that  the  vesicles  are 
pendant  in  the  uterine  cavity,  and  are  attached  to  a  membrane  that  lines 
either  the  uterine  parietes  or  the  coverings  of  the  e^g,  the  decidua  vera 
or  reflexa.  We  may  admit  that,  secreted  by  the  glands  of  the  uterine 
mucous  membrane,  they  push  its  most  superficial  layer  before  them,  and 
this  most  superficial  layer,  being  less  elastic,  gives  way,  and  is  torn  into 
filaments.  This  view  is  justified  by  the  microscopic  observations  of 
Sirelius  de  Helsiiigfords,  upon  the  modifications  of  the  elements  of  the 
uterine  mucous  membrane  during  pregnancy. 

Ancelet  concludes,  with  reservations,  as  follows:  "  The  hydatid  mole 
is  a  peculiar  alteration  of  one  of  the  surfaces  of  the  deciduous  membrane, 
arising  under  the  influence  of  impregnation,  and  consists  of  the  produc- 
tion by  successive  budding  and  exogenous  multiplication  of  independent 
vesicles,  adhering  to  one  another,  covered  by  a  common  membrane,  and 
tending  to  become  isolated  as  they  develop." 

Ancelet  thus  returns  to  the  ideas  of  those  authors  who  consider  the 
hydatid  mole  a  disease  of  the  decidua  and  not  of  the  chorion;  an  evident 
error,  since  its  seat  is  in  the  chorional  villi. 

But  there  are  still  other  opinions,  which,  while  admitting  the  seat  of 
the  affection  to  be  in  the  villosities,  differ  as  to  its  nature. 

Virchow  does  not  believe  in  any  dropsy  proper  of  the  chorional  villi. 


250  A   TREATISE   ON    OBSTETRICS. 

but  regards  the  affection  as  a  hj'pertropliy  of  pre-existing  mucoid  tissue. 
This  exists  in  the  umbilical  cord  abundantly,  and  is  called  the  gelatine  of 
Wharton,  and  also  in  other  portions  of  the  foetus.  We  may  denominate 
it  imperfect  fatty  tissue,  since  in  most  cases  it  developes  into  that  tissue 
later. 

It  is  a  distinctly  individual  tissue,  and  the  most  typical  tumors  formed 
of  it  are  found  in  the  f cetus  during  its  early  development,  and  in  the 
membranes  of  the  egg.  These  are  the  growths  which  have  been  described 
as  hydatid,  vesicular,  or  cystic  mole,  and  which  Virchow  calls  myxoma  of 
the  chorional  villi. 

This  condition  is  found,  he  says,  almost  without  exception  in  the 
human  egg  after  abortion,  while  it  is  rarely  seen  in  labor  at  term.  Usually 
a  large  mass  of  mixed  blood  and  vesicles  is  expelled.  On  removing  the 
former,  the  vesicles  are  seen  to  be  united  in  clusters,  so  that  each  vesicle 
has  a  pedicle,  and  the  larger  vesicles  give  insertion  upon  their  surface  to 
smaller  ones,  which  in  their  turn  support  others. 

Heinrich  Miiller,  on  the  other  hand,  places  the  affection  in  the  exter- 
nal membrane  covering  the  villi,  in  the  so-called  exo-chorion;  while 
Mettenheimer,  whose  opinion  is  shared  byPajot,  claims  that  there  occurs 
a  cystic  transformation  of  the  cells  contained  in  the  interior  of  the  villi. 

These  contradictions  are  due,  according  to  Virchow,  to  an  incomplete 
knowledge  of  the  structure  of  the  chorional  villi.  Virchow  was  the  first 
to  show  that  the  hypertrophied  villi  of  the  hydatid  mole,  as  well  as  the 
normal  villosities,  consist  of  prolongations  of  the  same  mucoid  tissue  that 
forms  the  gelatine  of  the  umbilical  cord;  that  the  villi  are  formed  of  two 
elements  only:  an  epithelial  covering  (exo-chorion)  and  a  substratum  of 
mucoid  tissue  (endo-chorion),  which  only  later  becomes  vascularized. 
The  epithelial  proliferation  of  Heinrich  Mtiller  is  simply  a  stage  in  the 
normal  development  of  that  tissue.  It  is  in  the  body  of  the  papilla  alone, 
and  not  in  the  epithelium,  that  the  peculiar  transformation  occurs  that 
leads  to  the  production  of  a  mole. 

In  fact,  these  growths  have  been  found  on  other  parts  of  the  envelopes 
of  the  egg,  both  Ruysch  and  Virchow  having  seen  them  upon  the  umbili- 
cal cord 

Normally,  only  those  villi  that  correspond  to  the  placenta  develop  pro- 
gressively; but  if  a  pathological  condition  supervenes  very  early  in  preg- 
nancy, they  all  proliferate  and  become  hyperplastic.  Abortion  usually 
follows;  but  it  may  happen  that  the  placenta  developes  normally,  only  a 
certain  group  of  villi  becoming  hydatid.  Usually,  however,  the  affection 
is  situated  just  at  the  j)lacental  site,  though  only  a  portion  of  the  cotyle- 
dons may  be  affected. 

In  any  case  the  affection  begins  as  a  multiplication  of  nuclei  and  cells. 

Whether  simple  hyperplasia  or  a  hydatid  state  results,  it  is  very  com- 
mon to  find  the  isolated  vesiculated  cells  which  Virchow  has  designated 


DISEASES    OF    THE    OVUM.  251 

Ijhysaliphores.  They  arc  found  in  the  epithelium  as  well  as  in  the  par- 
enchyma of  the  villi,  but  they  have  no  relation  to  the  development  of  the 
vesicular  mole.  The  morbid  process  corresponds  to  that  described  as  the 
mucoid  degeneration  of  cells.  Virchow  does  not  deny  that  some  cells 
may  disappear,  or  may  undergo  a  fatty  change;  but  they  often  persist  in 
great  number,  and  the  principal  accumulation  of  mucus  occurs  in  the  in- 
tercellular tissue.  Where  this  accumulation  is  relatively  large,  the  tissue 
becomes  cystic  in  appearance.  Where  the  fibrinous  portions  are  in  ex- 
cess, a  simple  hyperplasia  results. 

Thus  these  tumors  are  formed.  A  villus,  whose  normal  diameter  may 
be  hardly  half  a  line,  may  be  dilated  to  half  an  inch  or  more.  The 
larger  they  get  the  more  characteristic  they  become  of  mucoid  tissue. 
They  become  clear,  transparent,  and  gelatiniform;  they  contain  a  ropy 
liquid  which  gives  the  reactions  of  mucin. 

The  vesicular  appearance  depends  upon  the  delicacy  of  the  liquid-filled 
tissue. 

This  development  has  nothing  to  do  with  the  vessels;  but  if  it  occurs 
late  in  pregnancy,  the  vesicles  may  become  the  seat  of  an  extremely  rich 
capillary  plexus.  But  vessels  are  usually  absent,  at  least  in  eggs  coming 
from  the  first  months;  and  dropsy  of  the  amnion  and  atrophy  and  death 
of  the  foetus  occur  in  consequence  of  the  disease,  which  cuts  off  the  cir- 
culation. 

Hence,  the  different  descriptions  given  by  authors,  and  the  three  kinds 
of  hydatid  mole;  they  are  only  degrees  of  one  and  the  same  lesion,  vary- 
ing from  a  simple  fault}^  conformation  to  complete  destruction  of  the 
foetus  and  the  cord. 

Most  authors  regard  the  disease  of  the  membranes  as  the  primary,  and 
that  of  the  foetus  as  the  secondary  and  consecutive  affection. 

Hewitt  has  returned  to  the  first  theory,  and  it  is  the  true  one;  for  no 
one  has  yet  shown  that  the  placenta  continues  to  grow  when  retained 
after  the  death  of  the  fcetus.  The  villosities  remain  intact;  and  besides 
this,  the  condition  in  question  is  found  in  carnified  and  sanguineous  moles 
as  well  as  in  those  of  the  hydatid  variety;  but  it  is  very  likely  that  the  sec- 
ondary condition  is  not  then  due  to  a  myxoma,  but  to  the  hemorrhage 
which  produces  the  so-called  carnified  mole. 

Finally,  and  it  is  a  most  important  argument,  partial  myxomata  of  the 
placenta  occur  in  children  which  are  well  developed,  and  which  have 
died  during  the  last  months  of  pregnancy. 

The  lesion  of  the  membranes  is  then  the  original  one.  Does  it  begin 
as  an  irritation  of  one  of  the  uterine  surfaces,  or  does  it  come  by  the 
blood  of  the  mother  ?  The  fact  that  women  sometimes  have  hydatid  moles 
several  times,  and  that  in  them  the  decidua  plainly  shows  traces  of  inflam- 
matory thickening,  and  even,  according  to  Virchow,  little  polypoid  excres- 
cences, is  favorable  to  the  former  view.     A  more  or  less  extensive  endo- 


252  A   TREATISE    OF   OBSTETRICS. 

metritis  will  cause  sucli  hypertrophy  of  the  villi,  that  each  one  will  form 
a  true,  independent  tumor,  and  will  not  only  deprive  the  embryo  of  the 
nutritive  materials  which  they  should  supply  to  it,  but,  when  that  embryo 
is  destroyed,  can  continue  to  live  and  furnish  a  perfect  example  of  a  true 
parasitic  tumor,  heterologous  even  to  the  mother's  body,  and  yet  proceed- 
ing from  it. 

The  theories  concerning  the  vesicular  mole  may  be  summed  up,  as 
Duchamp  says,  in  the  following  propositions:  1st.  The  vesicular  mole  is 
entirely  independent  of  pregnancy;  2d.  The  vesicular  mole  increases 
under  the  influence  of  pregnancy,  but  is  not  due  to  disease  of  the  egg; 
3d.  The  vesicular  mole  is  due  to  a  change  in  the  product  of  conception, 
from — a.  Alteration  of  the  vascular  walls  (Cruveilhier) ;  b.  Alteration 
of  the  lymphatic  vessels;  c.  Dropsy  of  the  chorional  villi  (Kobin, 
Cayla);  d.  Myxomatous  degeneration  (Virchow  and  the  Germans,  Erco- 
lani,  Damaschino,  Cornil,  Ranvier,  Hirtzmann,  1874,  Josephson,  1879). 

The  vascular  and  lymphatic  theories  are  untenable,  and  if  true  hydatids 
have  been  expelled  from  the  uteri  even  of  virgins,  they  bore  no  likeness 
to  the  clusters  of  the  vesicular  mole. 

Ancelet's  idea,  that  it  is  a  disease  of  the  decidua,  is  wrong,  since  the 
degenerated  villi  might  contract  adhesions  to  the  decidua  without  that 
membrane  being  affected;  besides  which  the  villosities  have  been  seen  to 
be  continuous,  by  their  pedicles,  with  the  chorion. 

Euysch  and  Cruveilhier's  vascular  theory  is  disproved  by  the  fact  that 
the  vessels  are  not  dilated,  but  obliterated;  and  the  theory  of  the  lym- 
phatics is  in  complete  opposition  to  the  structure  of  the  villi. 

There  remain  the  two  theories  of  Eobin  and  of  Virchow.  Both  place 
the  morbid  change  in  the  villi,  but  Eobin  claims  that  the  vesicle  contains 
nothing  but  a  fluid,  in  which  a  few  cells  float  freely,  while  Virchow  holds 
that  what  fluid  there  is,  is  simply  the  intercellular  fluid  of  a  tissue.  The 
following  reasons  favor  the  latter  opinion:  1st.  The  normal  villus  con- 
tains mucoid  tissue;  it  is  not  astonishing  that  it  should  hypertrophy;  2d. 
The  vesicular  fluid  contains  mucin;  the  following  is  Grscheidlen's  analysis: 


Chloride  of  sodium. 

3.34 

Phosphoric  acid,    .... 

0.74 

Albumin,       ..... 

6.13 

Mucin,           ..... 

2.94 

Salts,     ...... 

6.25 

3d.  Virchow,  Cornil,  Eanvier,  Malassez  and  de  Sinety,  have  demon- 
strated the  identity  of  the  vesicular  mole  with  myxomata  of  other  regions. 

Causes. — The  vesicular  mole  is  rare,  and  is  found  oftenest  inmultiparae 
of  twenty-flve  to  forty  years.  A  molar  pregnancy  is  apparently,  to  a  cer- 
tain extent,  a  predisposing  cause.  As  to  its  etiology,  Euysch,  Scanzoni 
and  Graily  Hewitt,  flnd  it  in  the  death  of  the  fcetus;  but  moles  have 
been  found  with  living  children.     Virchow  attributes  it  to  endometritis. 


DISEASES    OF   THE    OVUM.  Z06 

and  this  is  the  generally  received  opinion  in  Germany  to-day.  It  is  prob- 
able that  the  myxomatous  lesion  begins  in  the  abundant  mucoid  tissue  of 
the  villosities,  and  that  this  tissue  becomes  infiltrated  with  fluid. 

Symptoms. — According  to  Depaul  three  symptoms  are  generally  found; 
but  they  may  be  wanting,  in  part  at  least:  1st.  Rapid  and  exaggerated 
development  of  the  abdomen  not  in  accordance  with  the  period  of  preg- 
nancy (Boivin,  Depaul);  2d.  Small  and  frequent  hemorrhages  of  a 
peculiar  character.  According  to  Percy,  there  is  an  alternation  of  small 
hemorrhagic  and  watery  flows,  commencing  in  most  women  at  the  second 
month,  and  continuing  at  longer  or  shorter  intervals  until  parturition. 
Gardien  observes  that  the  expulsion  of  hydatids  is  usually  accompanied 
by  hemorrhages  and  syncopes,  and  Depaul  has  observed  the  same  pecu- 
liarity; 3d.   The  expulsion  of  clusters  of  vesicles,  or  of  isolated  ones. 

Tliis  pathognomonic  sign  is  uilfortunately  rare,  and  when  it  does  occur, 
it  is  usually  shortly  before  the  expulsion  of  the  entire  mass. 

Diagnosis. — The  diagnosis  is  based  upon  these  symptoms,  and  is  diffi- 
cult to  make.  The  first  symptom  occurs  in  false  pregnancies,  and  with 
ovarian  cysts.  The  second  would  lead  one  to  think  of  cancer  of  the  cer- 
vix, and  of  a  vicious  insertion.     The  third  is  rare,  and  appears  too  late. 

To  make  the  diagnosis,  therefore,  both  the  first  signs  must  be  present 
during  the  first  months  of  pregnancy,  when  uterine  development  is  more 
easily  appreciated,  and  a  faulty  placental  insertion  is  not  likely  to  be  ac- 
companied by  frequent  hemorrhages. 

The  older  authors  did  not  consider  the  mole  as  always  due  to  preg- 
nancy, and  claimed  that  the  mammae  did  not  develop.  That  is  not  the 
case,  for  Cartereau  has  demonstrated  the  abundant  presence  of  milk. 
They  said  the  mother  did  not  feel  life;  but  there  are  moles  where  the  child 
is  born  living,  and  at  term.  Finally,  the  uterus  shows  the  ordinary  ine- 
qualities, and  all  the  signs  of  pregnancy,  nausea,  vomiting,  etc.,  may  be 
present. 

Prognosis. — 1st.  For  tlie  Motlier — Is  grave.  In  many  cases  the  mother 
succumbs,  not  from  the  development  of  the  mole,  but  from  hemorrhage. 
The  only  instance  where  death  could  be  attributed  directly  to  the  mole 
is  that  of  rupture  of  the  uterus  mentioned  by  Madame  Boivin.  The 
hemorrhages  are  usually  moderate  at  first,  and  usually  only  become  seri- 
ous towards  the  end  of  pregnancy,  and  at  the  moment  of  expulsion. 

There  are  several  instances  on  record  of  women  who  have  had  several 
vesicular  moles  (Depaul  cites  one  in  which  it  occurred  three  times) ;  but 
as  a  rule,  it  happens  only  once,  and  does  not  predispose  to  a  recurrence. 

2d.  For  the  Cliild. — It  is  always  serious.  In  the  two  first  varieties,  the 
child  is  liquified  or  dead;  in  the  third  it  is  almost  always  injured  and  ail- 
ing, and  ill -prepared  for  life. 

Treatment. — We  can  only  treat  the  hemorrhage  as  an  accident  of  the 
pregnancy.      General  measures  and  expectant  treatment,  if  it  is  slight; 


254  A    TREATISE    ON    OBSTETEICS. 

tamponing,  if  it  is  severe.  The  expulsion  of  a  few  vesicles  during  the 
pregnancy  does  not  affect  the  treatment.  If  labor  has  commenced,  and 
the  hemorrhage  is  serious,  tampon  again  if  it  is  thought  that  the  hydatid 
product  cannot  be  extracted.  If,  however,  that  can  be  done  either  manu- 
ally or  with  forceps,  it  should  be  at  once  resorted  to. 

Finally,  Breslau,  Eberth,  and  Spiegelberg,  have  described  another  form 
which  they  call  diffuse  myxoma  of  the  membranes.  It  consists  of  a  mucoid 
infiltration  of  the  chorion  by  a  homogeneous  mucoid  substance  with  thick 
fibres,  with  round  or  star-shaped  cells,  partly  'pliysalij)liores.  The  amnion 
is  thickened,  and  the  intermediate  layer  but  little  developed,  being  com- 
pletely absent  in  places.  The  superior  chorional  surface  shows  numer- 
ous flattened,  slightly  fluctuating  processes,  from  pea  to  cherry  sized.  A 
partial  myxoma  of  this  kind  has  been  demonstrated  by  Eokitansky  and 
Winogradow.  The  latter  found  a  goose-egg  sized  mucoid  mass,  soft, 
trembling  like  jelly,  and  absolutely  analogous  to  Wharton's  gelatine, 
some  three  inches  distant  from  the  placenta. 

Diseases  of  the  Amnions'. 

Like  the  decidua  and  the  chorion,  the  amnion  is  subject  to  various 
lesions  ;  but  there  is  one  of  more  importance  than  all  the  others  from  its 
influence  upon  the  mother  and  the  foetus.  We  refer  to  what  is  known 
as  dropsy  of  the  amnion  or  hydramnion. 

Dropsy  of  the  Amnion. 

Dropsy  of  the  amnion,  or  hydramnion,  consists  of  an  exaggerated  collec- 
tion of  fluid  in  the  amniotic  cavity.  As  Guillemet  remarks,  it  is  difficult 
to  fix  the  limit  at  which  the  amount  of  the  liquor  amnii  becomes  morbid, 
since  it  varies  considerably  in  a  state  of  health.  It  is,  therefore,  from 
the  phenomena  that  result  therefrom  that,  in  the  absence  of  any  precise 
point  of  departure,  we  decide  what  is  dropsy  of  the  amnion.  Btit  these 
phenomena  themselves  vary  with  the  individual,  and  with  the  rapidity 
with  which  the  secretion  accumulates;  so  that  an  arbitrary  limit  has  been 
fixed  upon,  and  all  authors  agree  that  when  the  quantity  of  the  fluid  ex- 
ceeds 32  to  48  ounces  there  is  dropsy  of  the  amnion. 

Frequency. — If  we  followed  the  statistics  we  should  hold  that  hydram- 
nion is  rare,  occurring  hardly  once -in  100  to-  150  confinements;  but  it  is 
really  far  commoner.  Typical  cases,  with  enormous  accumulation  of 
liquor  amnii  are  rare,  it  is  true,  but  a  relative  abundance  is  often  seen, 
the  ordinary  cases  passing  unnoticed;  for  the  accidents  that  occur  from 
it  depend  more  upon  the  rapidity  of  accumulation  than  upon  the  amount 
of  the  fluid.  This  accumulation  is  usually  slow  and  progressive,  and  is 
well  borne;  but  sometimes  the  effusion  is  more  rapid,  and  the  womb,  forced 
to  distend  itself  suddenly  and  excessively,  rebels,  and  gives  rise  to  certain 
peculiar  symptoms.    Jacquemier  and  Oulmont  only  have  carefully  studied 


DISEASES    OF    THE    OVUM.  255 

these  cases.  We  ourselves  have  seen  two,  Avhicli  are  described,  together 
with  those  which  we  have  been  able  to  collect,  in  our  memoir  on  liydram- 
nion,  1880. 

Etiologij. — We  must  now  return  to  the  theories  as  to  the  origin  of  the 
liquor  amnii.  The  theories  concerning  it  may  be  reduced  to  three:  1st. 
It  is  of  foetal  origin;  2d.  It  is  of  maternal  origin;  3d.  It  is  of  foetal  and 
maternal  origin. 

1st.  The  liquor  amnii  is  of  foetal  origin. — We  may  dismiss  the  ridicu- 
lous theories  of  Bolin,  avIio  derives  it  from  the  mammary  glands;  of  Lis- 
ter, who  draws  it  from  the  salivary  glands;  of  Warthon,  who  believed  that 
it  was  a  product  of  the  gelatinous  matter  of  the  cord,  and  even  of  the 
lachrymal  glands.  The  following  hypotheses  are  possible:  a.  The  liquor 
amnii  is  due  to  secretion  from  the  skin;  b.  It  is  due  to  secretion  from 
the  kidneys;  c.  It  is  due  to  a  transudation  of  the  liquid  parts  of  the 
foetal  blood,  through  the  amniotic  membrane;  d.  It  is  a  peculiar  secretion 
of  the  amnion. 

a.  Tim  liquor  amnii  is  secreted  by  the  shin. 

This  theory  originated  with  Galen.  Scherer  says  that  since  the  vernix 
caseosa  has  the  same  composition;  since  Schwann  found  pyine  in  the 
foetal  skin,  and  Eicholz  mucous  matter  in  the  new-born  at  term;  since  the 
umbilical  cord  produces  a  larger  quantity  of  water  than  its  return  vessels 
can  carry  away;  that,  therefore,  the  foetal  skin  excretes  a  watery  fluid. 
Nevertheless,  the  liquor  amnii  is  not  exclusively  produced  by  the  skin,  and 
the  presence  of  the  various  materials  in  the  amniotic  fluid  is  due  to  a 
simple  mixture. 

Schatz  attributes  a  considerable  influence  to  the  skin  upon  the  forma- 
tion of  the  liquor  amnii  during  the  latter  half  of  pregnancy.  The  high 
temperature  to  which  the  foetus  is  subjected  causes  excessive  secretion  of 
the  sweat,  and  the  liquor  amnii  contains  the  constituents  of  that  secre- 
tion. During  early  intra-uterine  life,  before  the  sudori porous  glands  are 
formed,  the  liquid  parts  of  the  fcetal  blood  transude  through  the  integu- 
ment. Bar  denies  this,  since  he  never  found  ferrocyanide  of  potassium, 
injected  into  the  veins  of  a  pregnant  rabbit,  in  the  liquor  amnii. 

b.  The  amniotic  fluid  is  due  to  the  tirinary  secretion  and  to  the  excretion 
of  the  urine  by  the  fcetus  into  the  amniotic  cavity. 

Gusserow  claims,  that  since  there  must  be  in  the  foetus  an  exchange  of 
nutritive  materials  and  activity  of  function,  after  the  obliteration  of  the 
allantois  at  the  second  month,  the  urine  must  flow  into  the  liquor  amnii; 
and  urea  and  ammonia,  absent  at  first,  increase  in  quantity  in  the  liquor 
amnii  as  pregnancy  progresses.  The  amniotic  fluid  is  thus  a  foetal  secre- 
tion. 

That  the  foetus  does  secrete  urine  is  incontestible,  and,  as  Bar  has  re- 
marked, may  be  demonstrated  in  three  ways:  1st.  By  anatomical  observa- 
tion, showing  that  the  kidneys  functionate  normally  during  uterine  life. 


256  A    TREATISE    ON    OBSTETRICS. 

since  urine  is  almost  alwaj^s  found  in  tlie  bladder  at  birth;  2d,  By  patho- 
logical observation,  which  teaches  us  that,  when  there  is  obliteration  of 
the  urinary  passages,  hydronephrosis  of  greater  or  less  extent  occurs.  The 
kidneys  are  normal,  save  where  modified  by  the  pathological  process, 
and  the  liquid  contained  in  the  urinary  passages  has  the  chemical  com- 
position of  Lirine.  If,  in  these  cases,  the  amount  of  liquor  amnii  is  not 
diminished,  it  is  simply  because  the  excretion  of  urine'  is  not  the  only 
source  of  the  liquor  amnii.  Finally,  uric  acid  infarctions  have  been  found 
in  the  kidneys  of  infants.  3d.  By  experiment,  Fehling,  Gusserow  and 
others  have  shown  that  certain  medicines  either  absorbed  by  the  m^other, 
and  thus  passing  through  the  placenta,  or  injected  directly  under  the 
foetal  skin,  could  be  refound  in  the  urine  of  the  foetus;  4th.  By  the 
chemical  composition  of  the  liquor  amnii. 

Prochownick  has  studied  the  chemistry  of  the  fluid,  and  has  proved 
the  presence  of  urea,  and  concludes  that  the  liquor  amnii  is  an  exclusive- 
ly foetal  product,  and  is  derived  from  the  nutritive  materials  of  the  foetus. 
The  quantity  of  urea  should  therefore  be  proportionate  to  the  energy  of 
nutritive  interchange.  In  point  of  fact  it  increases  largely  as  pregnancy 
advances,  and  the  kidneys  begin  to  functionate.  He  therefore  concludes; 
1st.  The  liquor  amnii  always,  after  the  sixth  week  of  pregnancy,  contains 
urea;  2d.  It  is  produced  by  the  skin  and  kidneys  of  the  foetus;  3d.  The 
quantity  of  urea  during  the  last  third  of  pregnancy  is  proportionate  to 
the  length  and  weight  of  the  foetus. 

In  a  second  chapter  he  proves  that  the  liquor  amnii  contains  chloride 
of  sodium,  and  from  a  quantitative  analysis  of  the  liquor  amnii,  he  con- 
cludes: 1st.  The  liquor  amnii  is  exclusively  a  foetal  product,  and  is  the 
product  of  the  interchange  of  foetal  nutritive  materials;  3d.  It  is  secreted 
by  the  skin  and  the  kidneys,  3d.  The  secretion  by  the  skin  begins  early 
in  pregnancy;  that  by  the  kidneys  commences  only  at  its  middle;  4th. 
The  amnion  is  a  serous  membrane,  and  can  absorb;  5th.  This  absorption 
becomes  more  and  more  easy  as  pregnancy  advances;  6th.  The  concentra- 
tion of  the  amniotic  fluid  increases  during  the  first  half  of  pregnancy, 
decreases  rapidly  at  its  middle,  and  thus  remains  about  the  same  until 
its  termination;  7th.  The  amount  of  the  fluid  at  various  times  will  be 
noted  later. 

Fehling  holds  that  the  albumin  in  the  liquor  amnii  precludes  the  pos- 
sibility of  its  being  a  purely  urinary  secretion,  since  there  is  none  in  the 
urine  of  living  children,  and  that  there  is  no  more  urea  in  the  fluid  of  the 
amnion  than  in  other  serous  fluids. 

c.  The  liquor  amnii  is  due  to  a  transudation  of  the  fluid  portions  of  the 
blood  through  the  amniotic  membrane. 

Both  Monro  and  Lobstein  have  seen  fluid  percolate  through  the  inter- 
nal surface  of  the  amnion  after  injecting  hot  water  into  the  umbilical 
arteries;  and  Jungbluth  has  found  a  minute  capillary  net- work,  which  he 


DISEASES    OF   THE   OYUAf.  257 

calls  the  vasa  propria,  in  the  superficial  placental  layer  nearest  to  the  am- 
nion, which  is  almost  always  obliterated  in  the  later  months  of  preg- 
nancy. This  he  considers  as  the  source  of  the  liquor  amnii,  and  hence 
it  is  that  that  fluid  is  nearly  identical  with  blood  serum  in  composition. 
An  excess  of  pressure  in  the  foetal  circulation  will  cause  a  transudation  in- 
to the  amniotic  cavity  from  this  capillary  plexus,  although  of  course, 
wlien  we  consider  the  length  of  the  cord  and  the  multiplicity  of  its  spirals, 
the  arterial  pressure  can  be  but  feeble. 

Gassner  considers  Jungbluth's  explanation  as  only  partially  sufficient, 
since  the  liquor  amnii  increases  during  the  second  half  of  pregnancy, 
when  this  capillai-y  plexus  has  been  obliterated.  The  foetal  urinary  se- 
cretion explains  its  continued  increase,  and  explains  the  cause  of  Gassner's 
law,  that  the  quantity  of  the  fluid  is  proportional  to  the  weight  of  the 
foetus.  Thus  the  relative  quantity  of  albumin  decreases  in  the  urine- 
diluted  fluid,  and  therefore,  in  cases  of  occlusion  of  the  foetal  urinary 
passages  in  the  later  months  of  pregnancy,  the  liquor  amnii  is  absent  or 
nearly  so.  But  while  Jungbluth's  theory  will  explain  certain  cases  of 
dropsy  of  the  amnion,  there  are  others  that  it  will  not  explain. 

Lebedjew  seeks  to  answer  the  following  two  propositions:  1st.  Does 
there  exist,  in  the  limiting  chorional  layer  of  children  at  term,  in  cases 
of  dropsy  of  the  amnion,  the  capillary  net- work  described  by  Jungbluth  ? 
2d.  What  circumstances  determine  this  persistence  of  vascular  permea- 
bility which  is  absent  under  normal  conditions  ? 

Lebedjew  has  proved  microscopically  the  existence  of  this  plexus  in  a 
case  of  hydramnion  with  a  dead  child;  but  there  existed  aortic  stenosis, 
hypertrophy  of  the  right  ventricle,  and  consequently  stasis  in  the  inferior 
vena  cava.  This  obstruction  to  the  flow  would  be  transmitted  to  the 
placenta  through  the  portal  and  umbilical  veins.  This  probably  interfered 
with  the  obliteration  of  the  plexus  in  question,  and  determined  the  in- 
creased transudation.  Lebedjew  claims  that  dropsy  of  the  amnion  is  due 
primarily  to  a  foetal  anomaly,  and  hence  arises  the  large  mortality  in 
these  cases 

Sallinger  holds  that  the  amniotic  fluid  is  derived  exclusively  from  the 
foetal  circulation;  coming  at  the  commencement  of  pregnancy  from  the 
foetal  skin,  later  from  the  cord  and  the  vessels  of  the  foetal  placenta,  and 
only  towards  the  end,  in  greater  or  smaller  quantity,  from  the  kidneys. 
Only  a  small  amount  of  fluid  is  derived,  during  the  early  months  of  preg- 
nancy, from  the  skin,  which  soon  becomes  covered  with  epidermis,  and 
secretes  less  freely;  the  greater  part  of  it  is  due  to  the  resistance  that  the 
foetal  circulation  encounters  in  the  placenta,  and  in  the  cord.  Excess  of 
resistance  will  cause  dropsy  of  the  amnion;  and  clinical  observation  shows 
that  obstruction  of  the  veins  that  bring  blood  to  the  foetus,  either  in  the 
placenta  or  the  cord,  or  at  the  umbilical  ring  or  in  the  liver,  is  the 
cause  of  the  affection. 
Vol.  11—17 


258  A   TREATISE    OlST    OBSTETRICS.    " 

Sallinger  thus  holds  that  hydramnion  is  due  to  mechanical  disturb- 
ances of  the  foetal  circulation,  or  to  variations  in  the  entire  mass  of  the 
foetal  blood,  and  not,  as  Jungbluth  says,  to  special  anatomical  conditions 
of  the  placenta.  He  performed  a  series  of  experiments,  which  tended  to 
prove  that  the  liquor  amnii,  whether  in  normal  or  abnormal  quantity,  is 
a  dn-ect  product  of  transudation  from  the  umbilical  vein  and  from  ita 
ramifications  in  the  placenta.  Taking  healthy  and  untoi'n  placentse,  and 
introducing  a  canula  into  the  umbilical  vein,  he  injected  under  a  con- 
stant pressure  pure  water  and  defibrinated  bullock's  blood.  The  injected 
liquids  transuded  through  the  amnion  with  great  rapidity;  thus: 

1st.  With  a  pressure  of  36  inches  upon  the  single  vein  of  a  small  cord, 
ihere  passed  in  one  hour  25.43  grains. 

2d.  With  the  same  pressure  and  a  thick  cord,  28.91  grains. 

He  once  employed  the  double  placenta  of  twins,  and  obtained: 

3d.  With  a  pressure  of  36  inches  on  both  veins  together,  56.31  grains. 

4th.  With  a  pressure  of  74  inches  on  the  vein  of  the  thick  cord,  and  of 
36  inches  on  the  vein  of  the  thin  one,  in  half  an  hour,  60.94  grains. 

5th.  With  a  pressure  of  50  inches  upon  the  thin  cord,  and  of  36  inches 
upon  the  thick  one,  in  half  an  hour  75.61  grains. 

6th.  With  an  equal  pressure  of  50  inches  on  both,  in  the  same  time, 
50.68  grains. 

Bar  has  repeated  these  experiments  of  Sallinger,  and  concludes  with 
him: 

1st.  Under  a  certain  pressure  the  fluids  contained  in  the  umbilical 
vein  may  transude  into  the  amniotic  cavity. 

2d.  Under  an  equal  pressure  fluids  will  not  transude  through  the  walls 
of  the  umbilical  arteries. 

These  two  theories  each  have  their  partisans  and  their  adversaries. 
Thus,  Winckler  has  never  been  able  to  prove  the  existence  of  Jungbluth's 
capillary  plexus,  but  believes  that  there  is  a  lymphatic  plexus  in  the  cel- 
lular layer  of  the  chorion,  which  opens  freely  into  the  cavity  of  the  egg 
through  the  amniotic  epithelium,  exactly  as  occurs  in  the  diaphragm. 
These  canaliculi  are  the  source  of  the  fluid  in  dropsy  of  the  amnion.  A 
considerable  dilatation  of  these  lymphatic  vessels  has  been  found  by 
Winckler  in  a  case  of  hydramnion  complicated  with  foetal  rachitis. 

Levison  and  Gusserow  siipport  Jungblutli's  theory.  The  former,  by 
means  of  injections  into  the  vessels  of  the  umbilical  cord,  found  the  capil- 
laries well  developed  in  the  membranous  lamina  of  the  placenta  of  pre- 
maturely born  infants,  while  in  those  born  at  term,  there  was  none;  but 
in  cases  of  hydramnion,  either  at  term  or  before  it,  he  found  it  very 
abundantly  developed. 

He  admits  the  presence  of  the  lymphatic  vessels  which,  with  Winckler, 
play  the  part  of  the  vasa  propria  of  Jungbluth.  May  not,  he  asks,  dis- 
turbances of  pressure  in  the  fcetal  circulation  pi'olong  the  permeability  of 


DISEASES    OF    THE    OVUil.  259 

the  vasa  propria  of  tbe  placenta,  and  thus  increase  the  amount  of  liquid 
that  passes  through  them. 

Weil  and  Waldeyer  also  admit  the  existence  of  Jungbluth's  vasa  pro- 
pria. Bar  contests  their  existence,  claiming  that  Jungbluth  never  de- 
scribed them  as  being  in  the  amnion,  but  only  as  being  in  contact  with 
its  lower  surface,  being  situated  below  it.  He  denies  the  correctness  of 
the  designation  vasa  propria,  especially  as  in  the  amnions  of  some  of  the 
lower  animals  there  exist  true  proper  vessels.  The  branches  of  the  um- 
bilical vein  that  ramify  over  the  foetal  surface  of  the  placenta,  give  off  a 
capillary  plexus  that  ramifies  and  anastomoses  with  itself,  and  then  pene- 
trates the  placental  tissue.  Injected  with  a  colored  fluid,  the  plexus  be- 
comes visible  to  the  naked  eye. 

We,  ourselves,  have  found  a  venous  net-work  applied  to  the  deep  face  of 
the  placentaj  but  never  a  capillary  one.  Nor  have  we  ever  been  able  to 
inject  it  with  prussian  blue.  Nevertheless,  we  do  not  absolutely  deny  its 
existence.  We  have,  ourselves,  seen  in  cases  of  dropsy  of  the  amnion  a 
considerable  turgescence  of  the  branches  of  the  umbilical  vein;  we  have 
even  in  one  case  seen  the  chorionic  vessels  more  largely  open  than  in  the 
normal  state;  but  Jungbluth^s  description  certainly  does  not  apply  to  all 
cases  of  dropsy  of  the  amnion,  and  permeability  of  the  vasa  propria,  to 
the  end  of  pregnancy,  cannot  be  the  sole  cause  of  the  affection.  For: 
1st.  If  the  vessels  are  obliterated  at  the  middle  of  pregnancy,  how  can  the 
quantity  of  the  liquor  amnii  increase  continuously  until  the  time  of  preg- 
nancy ?  2d.  We  have  been  unable  to  demonstrate  the  capillary  plexus  in 
some  cases  of  dropsy  of  the  amnion. 

As  to  Winskler^s  theory  of  a  sub-amniotic  capillary  plexus.  Bar  rejects 
it  also. 

d.   The  fluid  is  a 'peculiar  secretion  of  the  amnion. 

The  amnion,  according  to  Hotz,  is  often  covered  with  a  layer  of  cylin- 
drical cells,  and  Kolliker  records  a  case  in  which  there  were  many  am- 
niotic caruncles.     Buttheir  function  is  still  entirely  unknown. 

2d.  The  am^iiotic  fluid  is  a  product  of  the  maternal  organism. — Ahlfeld 
claims  that  in  consequence  of  the  eccentric  hypertrophy  of  the  uterus,  the 
pressure  upon  its  contents  is  less  than  the  abdominal  pressure;  and  since 
it  is  a  closed  cavity,  the  maternal  blood  must  necessarily  flow  into  it. 
This  negative  pressure  diminishes  progressively  up  to  the  third  month, 
when  it  ceases,  the  contents  thenceforward  developing  equally  with  the 
organ  itself.  The  serosity,  in  passing  from  the  vessels  to  the  egg,  traverses 
the  pores  of  the  chorion  and  of  the  amnion,  and  the  author  has  been  able 
to  prove  the  existence  of  blood-coloring  matter  in  these  pores,  which  had 
traversed  the  chorion  and  had  penetrated  to  the  epithelium  of  the  amnion. 

Leopold  agrees  with  Ahlfeld  so  far  as  the  first  months  of  pregnancy  are 
concerned;  and  Zuntz,  whose  experiments  have  proved  that  substances 
injected  into  the  maternal  vessels  may  pass  into  the  liquor  amnii  without 


260 


A    TREATISE    ON    OBSTETRICS. 


going  throngli  the  body  of  tlie  fcetus,  believes  tliat^  at  least  in  part,  tlie 
liquor  amnii  is  derived  from  the  maternal  blood.  Wiener  and  Bar  have 
repeated  Zuntz's  experiments,  and  have  arrived  at  the  same  conclusions. 

3d.  The  fluid  is  derived  both  frotn  the  onother  and  from  the  child. — ■ 
This  is  Virchow  's  opinion;  he  holds  that  the  foetal  portion  is  composed 
of  the  vernix  caseosa  and  renal  secretion,  the  rest  being  essentially  a  ma- 
ternal transudation. 

As  we  see,  theories  are  not  wanting;  but  the  real  cause  of  dropsy  of  the 
amnion  remains  to  be  found.  Whether  we  admit  that  the  liquor  amnii 
comes  from  the  mother,  or  whether  we  believe,  as  is  the  more  probable 
supposition,  that  it  is  produced  by  the  foetus  and  the  membranes,  it  in 
no  way  explains  the  occurrence  of  dropsy  of  the  amnion.  The  following 
facts  are  to-day  incontestible,  and  have  been  proved  by  various  observa- 
tions. 

1st.  Dropsy  of  the  amnion  coincides  very  frequently  with  twin  preg- 
nancy. 

2d.  Children  born  with  the  complication  of  dropsy  of  the  amnion  are 
often  the  subjects  of  malformations  and  monstrosities. 

3d.  A  certain  number  of  women  who  have  dropsy  of  the  amnion  are 
syphilitic,  and  their  children,  born  dead  or  living,  show  unmistakable 
signs  of  the  disease.  Finally  hydramnion  is  very  rare  in  primiparge,  and 
seems  to  be  especially  liable  to  occur  after  a  obtain  number  of  preg- 
nancies. 

Mac  Clintock,  in  33  cases,  found  primi parse  5;  second  pregnancies  8; 
third  to  twelfth  pregnancies  20. 

As  to  twin  pregnancies,  the  following  figures  will  suffice: 

Oulmont,  in  14  cases,  had   7  twin  births. 
Guillemet  "28     "         "15     " 

Sallinger  in  81  cases,  had: 

Primiparai,  19;  Multiparae,  49;  Unknown,  13. 

■n  .    .  ,,.     (  1  single  child,      .....         10 

Pnmiparae,  19,   -j  ^  ^^.f^^^^^^  ......  9 

r  1  single  child, 31 

Multiparae,  49,    UrTpTets,      .'         .'         .'         '.         \         '.         ^1 
[Quadruplets, 1 

TT  1              1  o      i  1  single  child,      .....         10 
Unknown,  13      \  rj.^.^^^         / 3 


Thus,  in  81  cases  there  were  : 

Simple  pregnancies. 
Multiple       "  .         . 


81 


51 

30 


81 


DISEASES    OF    THE    OVUM.  261 

In  tlie  114  children,  1  of  wliich  was  a  case  of  extra-uterine  pregnancy, 
there  were:  girls,  23;  boys,  38;  unknown,  53. 

Can  we  explain  the  coincidence  of  dropsy  of  the  amnion  with  twin 
pregnancy?  Is  it  exaggerated  uterine  development,  or  the  stretching  of 
the  membranes,  or  compression  of  one  foetus  by  the  other,  or  is  there 
anything  peculiar  about  the  circulation  or  the  blood  pressure,  or  in  the 
arrangement  of  the  placenta  and  membranes  that  accounts  for  it  ?  It  is 
impossible  to  say.  We  know  that  there  may  be  one  of  four  conditions 
present  in  these  twin  births: 

1st.  A  single  placenta,  chorion,  and  amnion,  with  a  communication 
between  the  two  foetal  circulations. 

2d.  A  single  placenta,  chorion  and  amnion,  with  an  almost  constant 
communication  between  the  two  circulations;  or  one  chorion  and  two 
amnions,  with  a  rarer  communication. 

3d.  Two  isolated  placentae,  united  by  a  membranous  bridge;  rarely 
communication  between  the  two  circulations;  often  two  chorions  and  two 
amnions. 

4th.  Two  entirely  distinct  placentae,  two  chorions  and  two  amnions;  no 
communication  between  the  two  circulations. 

Frankenhauser  only  seems  disposed  to  admit  hydramnion  as  possible  in 
cases  where  there  exists  a  communication  between  the  two  foetal  circula- 
tions. In  consequence,  he  claims  that  the  cardiac  activity  of  the  stronger 
foetus  causes  cardiac  stasis  in  the  weaker  one,  and  hence  increased  trans- 
udation on  that  side.  Schatz  agrees  with  this  opinion,  and  says:  "  The 
child  that  has  the  more  powerf  al  heart  will  have  the  greater  arterial  pres- 
sure, will  secrete  more  urine,  and  have  more  liquor  amnii."  To  this  Sal- 
linger  rightly  objects  that  in  that  case  we  should  have  hydramnion  in 
twin  pregnancy  with  an  acardiac  foetus;  whereas  this  has  not  been  found. 

Every  variety  of  malformation  has  been  found  with  dropsy  of  the  am- 
nion, from  hydrocephalus  and  spina  bifida,  to  anencephalus,  harelip, 
clubbed  feet  and  hands,  double  monstrosities,  etc.  Internal  deformities, 
malformations  of  the  heart,  imperforate  genital  organs,  etc.,  have  also 
been  noted. 

And  if  some  of  these  malformations,  such  as  an  imperforate  urethra, 
will  explain  hydramnion,  the  others  will  not  do  so,  and.  we  must  return 
to  the  opinion  of  Burns,  who  said :  "'  Dropsy  of  the  amnion  is  a  disease  of 
the  egg,  and  not  of  the  mother;  the  foetus  is  often  deformed,  and  the 
affection  must  be  considered  as  a  species  of  monstrous  conception."  As 
to  syphilis,  Burns,  in  1839,  had  already  proved  that  hydramnion  might 
occur  with  syphilis  of  the  father  or  the  mother.  Fournier  has  recently 
again  called  attention  to  this  relationship,  as  have  Bourgarel,  Preel,  De- 
paul,  Gueniot,  Charpentier,  Sallinger,  etc. 

In  some  cases  of  hydramnion  with  syphilis,  the  foetus  shows  indubitable 
marks  of  the  disease;  but  in  others  neither  foetus,  placenta,  nor  mem- 


262  A   TREATISE    ON    OBSTETRICS. 

branes  showed  the  least  sign,  and  we  are  compelled  to  admit  the  efl&- 
ciency  of  the  maternal  influence.  To  these  three  main  facts — twin  preg- 
nancies, .foetal  malformations,  and  syphilis — we  must  add  lesions  of  the 
ovum  and  membranes  of  various  kinds. 

In  the  four  ca£3s  of  syphilis  we  observed  in  two  years  of  clinical  ser- 
vice, there  was  bit  a  single  case  of  dropsy  of  the  amnion.  The  woman 
had  dropsy  of  the  amnion  in  1875,  has  since  had  two  healthy  children 
while  under  specific  treatment,  and  is  at  the  present  moment  enceinte 
for  the  fourth  time,  and  shows  a  small  amount  of  amniotic  dropsy. 

The  anomalies  of  the  cord  may  cause  a  stasis  in  the  venous  circulation 
of  the  placenta. 

Hildebrandt  has  noticed  the  connection  between  these  anomalies  and 
the  hydatid  mole;  indeed  the  hydatid  mole  is  often  accompanied  by  a  large 
amount  of  liquor  amnii. 

Among  these  anomalies  of  the  cord,  Sallinger  notices:  Extreme  thin- 
ness; exaggerated  torsion;  cystic  degeneration;  stenosis  of  the  umbilical 
vein;  rings  of  the  cord. 

There  may  be  also  cartilaginous  and  hepatic  degeneration  of  the  placen- 
tal tissue,  fibro-myxoma  of  the  placenta;  atrophy  of  the  placenta;  hyper- 
trophy of  the  placenta  ;  abnormality  of  the  hepatic  circulation.  On  the 
side  of  the  mother  there  may  be  hydraemia,  tumors,  especially  fibroids,  and 
carcinoma  uteri. 

As  to  the  membranes  themselves,  they  may  be  the  seat  of  a  multitude 
of  inflammatory  and  other  lesions,  concerning  which  we  have  recorded  a 
number  of  observations  in  our  Memoire. 

Finally,  G-ervis  decided  that  the  liquor  amnii  came  from  the  amnion, 
and  its  excessive  accumulation  was  due  to  serous  extravasation.  In  most 
cases  we  can  detect  either:  1st.  Inflammation  of  the  amnion;  2d.  A  hy- 
pertrophic and  morbid  decidua,  the  amnion  remaining  healthy;  the  foetus 
is  compromised,  and  abortion  is  imminent;  3d.  Dyscrasias  of  the  mater- 
nal blood,  such  as  cause  serous  transudations  in  oUier  parts  of  the  body. 

Symijtotns. — By  dropsy  of  the  amnion,  we  mean  a  disease  in  which  the 
amniotic  cavity  contains  an  abnormally  large  amount  of  fluid.  It  may 
exist  alone,  or  be  accompanied  by  other  dropsies,  as  ascites  (Scarpa);  and 
it  shows  itself  in  two  forms,  sufficiently  distinct,  though  not  very  sharply 
divided  from  one  another.  One  is  the  slower,  classical  form;  the  other, 
more  acute,  has  been  described  by  Oulmont  and  Jacquemier.  The 
symptoms  are  different  enough  to  justify  expectant  treatment  in  the  one 
case,  and  to  call  for  active  interference  in  the  other.  Let  us  first  de- 
scribe the  symptoms  of  the  ordinary  classical  dropsy  of  the  amnion. 

Gassner  has  found  that  there  is,  on  the  average. 

At  7  months,  32  ounces,  "1 

''  8        ''         43       "         [      ... 

a  ^        a         r^       i,         >  01  liquor  amnii. 

"  term,  60       "        J 


DISEASES    OF    THE    OVUM.  263 

This  quantity  is  doubled  in  twin  pregnancies.  The  figures,  of  course, 
are  not  by  any  means  exact.  Gassner  also  found  that,  in  general,  the 
amount  of  liquor  amnii  increased  proportionately  with  the  weight  of 
foetus  and  placenta.  The  amount  of  fluid  present  with  hydramnion  is 
very  variable.  Sallinger  has  collected  the  following  cases:  Schneider,  60 
pounds,  24  pints;  0.  Reilly,  48  pounds,  with  20  pounds  of  ascitic  fluid; 
Hansen^  over  two  buckets  full;  G-.  de  Gorregues  Griffith,  40  pounds; 
Battson,  32  pints;  Haerlin,  30  pounds;  Klink,  more  than  a  bucket 
full;  Pelletan,  2^  pounds;  Werner,  15  pounds;  Eouger,  15  pounds; 
Martin,  14  pounds;  Eidder,  14  pounds;  Eamsbotham,  15  pounds,  with 
25  to  30  pounds  of  ascitic  fluid;  \^alenta,  5  pounds;  Fabrice  de  Hilden, 
2'X  pounds;  Sallinger,  30  pounds. 

It  thus  takes  flve  pounds  to  cause  trouble  during  pregnancy  and  child- 
birth; but  as  a  rule  the  amount  varies  between  10  and  60  pounds. 

Usually  the  disease  does  not  commence  before  the  fifth  or  sixth  month 
of  pregnancy,  although  it  occasionally  appears  earlier.  Thus  the  case 
of  Fabrice  de  Hilden  dated  from  the  beginning  of  pregnancy;  those  of 
Scarpa,  Schneider,  Hahn,  Depaul,  and  Menschler,  from  the  end  of  the 
second  month;  those  of  Martin,  Pelletan,  and  Gueniot,  from  the  third 
month;  that  of  Eausch,  Werner  and  Eouger  from  the  fourth  month,  and 
that  of  Seulen  from  the  fifth  month. 

The  first  symptom  is  the  appearance  of  persistent  vomiting,  followed  by 
general  enfeeblement,  and  marked  emaciation.  But  these  symptoms  are 
not  constant,  and  much  more  characteristic  are  the  pains,  which  are  seated 
sometimes  in  the  belly,  sometimes  in  the  hypogastrium,  or  even  in  the 
sacral,  inguinal,  or  lumbar  regions;  they  are  usually  continuous,  though 
they  may  be  intermittent  and  take  on  the  character  of  uterine  contrac- 
tions. They  do  not  appear,  usually,  until  pregnancy  has  advanced  to  a 
certain  point. 

Then  comes  a  rapid  and  exaggerated  development  of  the  abdomen,  ac- 
companied by  thinning  of  the  uterine  parietes,  and  by  fluctuation.  This 
sensation  of  fluctuation  is  never  seen  in  normal  pregnancies,  and  has  been 
found  so  pronounced  as  to  have  been  mistaken  for  ascitic  fluctuation. 
More  often,  however,  there  is  a  sensation  of  false  fluctuation,  exactly  like 
that  experienced  in  cases  of  ovarian  cysts.  We  will  return  to  this  subject 
when  we  come  to  speak  of  diagnosis. 

The  abdominal  development  usually  begins  early  in  pregnancy,  but 
does  not  become  very  marked  vmtil  after  the  fourth  or  flfth  month.  Al- 
though it  advances  rapidly,  and  out  of  all  proportion  to  the  supposed 
stage  of  the  pregnancy,  it  progresses  evenly,  and  may  reach  an  enormous 
development.  Hence  the  morbid  symptoms  are  not  very  intense,  and  it 
is  only  after  the  disease  has  existed  for  some  time,  that  the  women  begin 
to  suffer  much,  The  uterus,  in  fact,  does  not  react  very  energetically 
against  the  progressive  liquid  accumulation.  Hence  the  relative  tolerance 
to  and  benignity  of  the  affection. 


264  A    TREATISE    ON    OBSTETRICS. 

In  consequence  of  the  abdominal  distension  and  increased  intra-abdomi- 
nal pressure,  a?dema  appears.  It  may  be  limited  to  the  lower  limbs,  or 
appear  on  different  parts,  such  as  the  genitals  or  the  abdominal  wall. 
But  its  consequence  may  be  more  serious,  and  ascites  appear.  (Edema 
is  not  a  constant  symptom,  and  is  absent  in  many  well-pronounced  cases. 

In  consequence  of  the  great  abdominal  distension,  other  symptoms  ap- 
pear indicative  of  compression  of  the  lungs:  dyspnoea,  oppression,  engorge- 
ments of  the  base  of  the  lung,  oedema  pulmonum,  with  syncopes  and  as- 
phyxias, and  in  some  cases  even  real  hemorrhages. 

Cardiac  palpitation  naturally  ensues,  and  the  pulse  becomes  small  and 
frequent. 

The  urine  is  diminished  in  quantity;  it  is  thick,  reddish,  and  more  or 
less  highly  charged  with  albumin.  A  dysuria  more  or  less  pronounced 
appears  at  the  same  time;  and  in  rare  cases  there  may  be  some  icterus. 

Constipation  is  the  rule.  Then  nervous  troubles  appear,  vague  neural- 
gic pains,  especially  marked  in  the  lower  limbs. 

Insomnia,  with  agitation  and  depression  of  spirits,  may  now  appear; 
and  in  some  rare  cases  psychic  troubles,  delirium,  trismus,  and  even 
eclampsic  attacks  may  follow. 

It  is  a  curious  fact  noticed  by  Sallinger,  that  in  most  cases  there  is  no 
fever. 

The  extreme  distension  of  the  abdomen  causes  thinning  of  the  uterus, 
the  vagina  is  shortened,  the  cervix  effaced,  and  often  partly  open.  The 
presenting  part  is  very  mobile,  and  ballottement  is  very  marked. 

The  foetal  heart-sounds  are  usually  feeble;  they  change  their  place,  and 
sometimes  become  inaudible  towards  the  close  of  pregnancy;  in  some  cases 
they  may  never  have  been  perceived. 

The  hyper-distended  membranes  are  often  ruptured  too  early,  and  pre- 
mature labor  occurs. 

Finally,  metrorrhagia  is  common  during  pregnancy,  and  occurs  during 
labor,  and  especially  after  delivery  from  uterine  inertia.  Such  are  the 
principal  symptoms  of  dropsy  of  the  amnion;  but  we  must  consider  some 
of  them  more  in  detail,  especially  the  abdominal  tumor,  and  the  sensa- 
tions obtained  by  palpation. 

The  shape  of  the  abdomen  is  peculiar.  In  the  place  of  a  distinct  pro- 
tuberance surmounted  by  a  depression,  the  belly  is  evenly  swollen,  es- 
pecially in  front,  while  the  lateral  portions  appear  to  be  depressed. 

In  some  cases  Guillemet  has  noticed  peculiar  deformities.  Thus  he 
has  seen  the  uterine  volume  so  considerable,  that  the  upper  part  of  the 
abdomen  projected  in  front  of  the  sternum,  and  the  sides  of  the  abdomen 
swollen  out  with  a  deep  cleft  in  the  middle,  so  that  it.  resembled  the  heart 
in  a  pack  of  cards.  We  may  notice  in  addition  a  supra-pubic  oedema,  often 
considerable,  and  finally,  that  this  form  of  belly  remains  the  same,  what- 
ever be  the  position  taken  by  the  woman. 


DISEASES  OF  THE  ovmi.  265 

There  is  a  large  area  of  dull  percussion,  sometimes  occupying  almost 
tlie  whole  abdomen,  and  tympanitic  intestinal  percussion  can  only  be 
found  at  the  sides,  where  a  sonorous  and  fixed  percussion  note  will  be 
found  when  the  distension  is  large. 

Palpation  gives  different  results  according  to  the  intensity  of  the  dis- 
ease and  the  time  at  which  it  is  practised. 

At  the  beginning,  the  uterus  is  readily  appreciable  to  the  hand  through 
the  soft  abdominal  walls.  Later,  they  not  only  become  harder,  but  the 
distended  uterus  is  so  intimately  applied  in  some  cases  to  the  abdominal 
walls,  that  it  is  only  to  be  distinguished  from  it  by  its  faint  contractions. 
The  abdominal  walls  are  sometimes  very  oedematous,  sometimes  thinned 
out  and  very  white  and  pale;  or  the  skin  may  be  covered  with  reddish  or 
bluish  blotches,  and  appear  ready  to  break.  In  the  first  case  the  sense 
of  fluctuation,  and  the  perception  of  the  foetal  part,  will  be  nearly  or 
quite  imperceptible  to  the  touch;  in  the  other  case,  fluctuation  may  be 
so  distinctly  perceived  that  the  fluid  appears  to  be  contained  in  the  peri- 
toneal cavity. 

Fluctuation  may  be  absent  entirely..  (Chereau.)  It  is  the  same  pre- 
cisely with  the  recognition  of  fcetal  parts.  Sometimes  ballottement  is 
very  easy,  and  sometimes  it  is  very  difficult  to  obtain.  Besides  the  diffi- 
culties created  by  the  distension  of  the  abdominal  wall,  the  distension 
of  the  uterus  itself  is  of  great  importance;  and  when  the  dilatation  of  the 
organ  is  great,  and  the  foetus  is  small,  it  is  often  difficult  to  feel  it,  and 
to  appreciate  its  presence.  Twin  pregnancies,  and  death,  which  alters 
the  density  and  firmness  of  the  foetus,  increase  these  difficulties.  The 
same  things  apply  to  the  vaginal  touch.  It  is  true  that,  in  most  cases, 
vaginal  ballottement  is  very  easily  obtained;  but  in  some  cases  it  cannot- 
be  gotten  at  all.  The  finger  feels  a  soft  mass  filling  the  vagina,  or  an 
elastic  and  hyper-distended  pouch,  but  no  presenting  part  is  appreciable. 

Finally,  the  exaggerated  sensibility  of  the  abdominal  walls,  which  are 
sometimes  so  tender  that  patients  can  hardly  bear  the  weight  of  their 
clothes,  is  an  obstacle  to  palpation:  and  the  oedema  and  tenderness  of  the 
genitals  make  a  vaginal  examination  so  painful,  and  the  sensations  are 
so  incomplete,  that  the  perception  of  the  foetal  parts,  if  not  impossible,  is 
extremely  difficult.  The  other  symptoms  we  will  find  more  marked  in 
the  acute  form  of  dropsy  of  the  amnion. 

Besides  this,  which  Ave  may  call  the  classical  form  of  the  malady,  and 
which  is  relatively  common,  there  is  another,  which  is  much  rarer,  and 
of  which  we  have  only  been  able  to  collect  twenty-one  cases,  two  of  which 
we  ourselves  have  seen. 

jSTevertheless,  we  believe  that  we  can  justify  our  division  of  the  rapid 
cases  from  those  that  we  call  the  classical  ones.  One  prime  fact  confronts 
us;  and  that  is  that,  while  in  the  ordinary  form  the  dropsy  takes  several 
months  to  attain  its  maximum,  in  the  other  it  takes  only  from  a  few  days 


266  A    TREATISE    02s"    OBSTETRICS. 

to  three  weeks  at  the  utmost  for  the  belly  to  be  enormously  swollen,  and 
for  symptoms  so  grave  to  appear  that  the  life  of  the  woman,  as  well  as 
that  of  the  j)rodnct  of  conception,  may  be  compromised.  For  while,  in 
the  first  instance,  the  uterus  has  time  to  accustom  itself  to  the  distension, 
in  the  second  case  it  is  suddenly  invaded  by  the  enormous  liquid  accumu- 
lation, and  reacts  against  it. 

And  here  we  meet  a  second  difference.  While  in  the  classical  hydramnion 
fever  is  so  exceptional  that  Sallinger  only  found  it  recorded  in  two  out  of 
the  eighty-one  cases  he  collected,  it  is  the  invariable  rule  in  the  second 
class,  and  gives  the  disease  an  inflammatory  appearance.  Acceleration 
of  the  pulse,  and  increase  of  the  temperature,  have  never  been  absent  in 
a  case  of  acute  dropsy  of  the  amnion.  (See  observations  of  Charpentier, 
Cerne,  Sentex,  etc.) 

Authors  have,  therefore,  sought  to  attribute  acute  hydramnion  to  in- 
flammation of  the  membranes. 

Besides  these  distinctive  points  there  is  a  third;  in  acute  dropsy  the 
symptom  of  vomiting  assumes  an  exceptional  intensity  and  gravity.  In 
the  two  cases  that  we  have  seen,  it  was  so  severe  that  the  patients  could 
eat  nothing  at  all.  The  vomit  is  at  first  composed  of  food,  then  of  mucus 
and  bile;  very  great  abdominal  pains,  with  a  feeling  of  heat  and  burning, 
accompany  it,  and  reduce  the  jiatient  to  a  condition  of  most  alarming 
debility. 

Alimentation  becomes  almost  impossible;  milk,  bouillon,  alcohol,  noth- 
ing can  be  retained;  the  woman  loses  flesh  with  extreme  rapidity,  and 
the  contrast  between  the  volume  of  the  stomach  and  that  of  other  jDarts 
of  the  body  is  very  striking.  The  shrivelled  face,  the  hollow  eyes,  bril- 
liant with  fever,  and  the  pinched  and  tightly  drawn  lips,  sufficiently  in- 
dicate the  serious  condition  of  the  sick  woman. 

At  the  same  time,  the  pains  are  characteristic  in  their  extreme  inten- 
sity; occupying  the  entire  abdomen,  they  shoot  down  into  the  loins  and 
thighs.  They  cease  neither  day  nor  night,  depriving  the  patient  of  all 
^leep,  and  are  exacerbated  by  movement  on  her  part.  The  dorsal  position 
does  not  ease  her,  and  she  can  neither  stand  nor  sit;  she  lies  crouched  in 
bed,  in  the  most  curious  positions,  writhing  occasionally  under  exacer- 
bations of  the  pain.  She  weeps  and  sighs,  piteously  demands  relief,  and 
cries  out  inarticulately.  Treatment  is  useless;  neither  quinine  nor  opium, 
nor  chloroform,  nor  chloral,  nor  morphine  injections  are  of  avail.  The 
pains  keep  the  patient  in  a  pei-petual  state  of  agitation;  the  fever  and  the 
pain  increase  continuously  as  the  belly  is  distended.  Deprived  of  sleep, 
and  with  a  constant  fever,  with  frequent  vomitings  and  exacerbations 
of  pain,  the  woman  soon  sinks  into  a  state  of  profound  exhaustion,  and 
cries  loudly  for  the  relief  which  it  seems  impossible  to  give  her. 

The  abdominal  distension  increases  continuously.  Althougli  it  attains 
^.n  enormous  size  in  a  few  days,  it  grows  steadily  though  more  slowly  after 


DISEASES    OF    THE    OVUM.  267 

the  first  outburst,  until  it  readies  proportions  that  are  frightful.  Espe- 
cially is  this  the  case  in  twin  pregnancies.  (Edema  of  the  abdominal 
walls,  especially  marked  above  the  pubis,  where  the  skin  forms  a  kind  of 
sac,  adds  to  the  distress,  and,  causing  swelling  of  the  labia  majora  and 
minora,  interferes  with  micturition.  The  urine  itself  is  scanty,  dark  in 
color,  and  turbid,  and  contains  a  variable  quantity  of  albumin. 

Usually,  after  a  certain  time,  the  patient  feels  other  abdominal  pains, 
which,  from  their  intermittent  character,  are  readily  recognized  by  mul- 
tipara as  uterine  contractions.  Although  not  a  constant  phenomena, 
this  is,  as  we  shall  see,  of  great  value  in  diagnosis. 

The  abdomen  has  now  assumed  the  form  that  we  have  described  in  the 
more  ordinary  variety  of  hydramnion;  but  palpation  is  almost  impractica- 
ble from  the  pain  it-  causes  the  woman.  Where  it  can  be  employed,  it 
does  not  give  us  the  same  results  as  regards  ballottement  and  fluctuation 
as  it  does  in  the  other  cases. 

If  the  abdomen  is  very  oedematous,  palpation  is  useless.  If  it  is  not 
oedematous,.  Ave  feel  the  uterus  as  a  thin-walled  mass,  which  gives  to  the 
finger  an  elastic  sensation,  but  no  feeling  of  fluctuation,  exactly  as  an  ex- 
tremely distended  ovarian  cyst  would  do.  It  is  in  vain  that  we  search  the 
mass  for  foetal  parts.  Percussion  and  auscultation  give  only  negative  re- 
sults, and,  if  we  have  not  studied  the  disease  from  the  beginning  of  preg- 
nancy, we  are  liable  to  make  grave  errors  in  diagnosis.  As  to  volume, 
the  abdomen  may  take  on  enormous  dimensions.  In  our  second  case,  at 
5-|  months,  the  abdomen  measured  52.8  inches. 

In  some  cases,  as  in  this  one,  the  abdomen  permits  a  special  sensation 
to  be  perceived,  which  enables  us  to  establish  the  diagnosis,  though  seve- 
ral examinations  are  necessary  for  the  purpose.  Thus,  at  our  first  visit, 
the  uniformly  distended  abdomen  allowed  us  only  to  feel,  in  the  right  iliac 
region,  a  hard  and  specially  painful  point,  which  gave  the  sensation  of  a 
thick-walled  multilocular  ovarian  cyst.  At  the  second  examination,  made 
two  days  later,  on  gently  palpating  the  abdomen,  which  had  in  the  mean- 
time increased  f  of  an  inch  in  circumference,  we  first  found  again  the 
same  sensation.  But  on  palpating  in  the  right  iliac  region,  we  found  the 
sensation  of  hardness  to  increase  under  the  pressure,  diminishing  markedly 
as  it  was  relaxed.  At  the  same  time,  this  hard  point  seemed  to  increase 
in  extent,  and,  prolonging  itself  towards  the  upper  part  of  the  abdomen, 
gained  the  epigastric  depression  by  a  curved  track;  and  on  placing  the  left 
hand  on  the  epigastrium,  it  was  plainly  felt  to  become  harder.  Then  the 
abdomen  appeared  to  change  a  little  in  shape;  it  gradually  became  more 
prominent  in  front,  the  lateral  portions  becoming  depressed.  This  sensa- 
tion of  a  contracting  organ  could  be  given  by  nothing  but  the  uterus,  and 
decided  the  diagnosis.  It  is  easy  to  understand  the  importance  of  this 
sign,  which  of  course  will  be  more  difficult  to  appreciate  where  dropsy  of 
the  amnion  is  complicated  with  ascites. 


268  A   TREATISE    OK    OBSTETRICS. 

The  intestine  shares  in  tlie  general  derangement.  XJsnally  there  is  a 
more  or  less  obstinate  constipation,  sometimes  interrupted  by  a  diarrhoea 
which  may  persist  for  several  days. 

The  yaginal  touch,  which  apparently  should  give  us  definite  informa- 
tion, and  does  so  in  certain  cases,  is  insufficient  in  others. 

The  marked  oedema  of  the  external  genitals  interferes  with  the  intro- 
duction of  the  finger,  and  limits  the  field  of  exploration.  The  changes 
in  the  cervix  are  sometimes  difficult  to  appreciate  at  three  months.  At 
the  fundus  vaginse,  we  feel  only  a  more  or  less  elastic  mass,  which  might 
as  well  belong  to  an  ovarian  cyst  as  to  a  uterus  distended  by  one  or  seve- 
ral foetuses.  The  foetus  cannot  be  reached,  nor  can  the  change  from  the 
neck  to  the  inferior  portion  of  the  uterus  be  appreciated  by  the  finger. 
The  only  tiling  that  we  can  be  sure  of  is  that  the  uterus  is  fixed  and  the 
cervix  but  little  developed.  Eectal  touch  did  not,  in  our  second  case, 
give  us  any  more  exact  information.  The  vital  importance  of  a  precise 
diagnosis  for  the  woman,  is,  however,  easily  appreciable.  Happily,  in 
most  cases,  the  diagnosis  of  pregnancy  has  been  made  beforehand,  and 
the  field  of  error  is  thus  limited. 

Thus  acute  dropsy  of  the  amnion  differs  in  its  symptoms  and  its  course 
from  the  slower  form,  and  it  is  liable  to  cause  errors  of  diagnosis,  which 
may  have  most  serious  consequences  for  the  patient.  For  energetic 
treatment  will  not  only  relieve  them,  but  will  remove  the  threatening 
dangers;  while  they  will  surely  succumb  if  the  disease  be  left  to  its  own 
course. 

Happily,  nature  herself  sometimes  effects  a  cure  by  means  of  premature 
labor;  but  in  only  too  many  cases  the  contractile  power  of  the  uterus  is 
much  impaired  by  the  distension;  and  then  the  obstetrician  must  inter- 
fere, and,  by  perforating  the  membranes,  bring  on  the  labor. 

Diagnosis. — The  diagnosis  of  dropsy  of  the  amnion  presents  several 
points  for  examination:  1st.  The  recognition  of  pregnancy;  2d.  The  de- 
termination whether  it  is  single  or  twin;  3d.  The  recognition  of  dropsy 
of  the  amnion,  and  its  differentiation  from  hydrorrhoea,  ascites,  the  vesi- 
cular mole,  and  ovarian  cysts;  4th.  The  determination  of  the  cause  and 
the  nature  of  the  dropsy. 

1st.  Tlie  Recognition  of  Pregfiancg.—This  is  sometimes  difficult  in 
normal  cases,  and  it  is  not  astonishing  that  it  should  be  more  so  in  cases 
complicated  with  hydramnion.  In  ordinary  pregnancies  we  have,  besides 
the  probable  signs,  only  active  foetal  movement,  the  foetal  heart-beat,  and 
ballottement  as  positive  evidences  of  pregnancy.  The  first  of  these, 
active  foetal  motion  may  easily,  in  dropsy  of  the  amnion,  escape  the 
notice  both  of  the  mother  and  of  the  accoucheur.  Lost,  so  to  speak,  in 
the  liquor  amnii,  the  movements  of  the  child  are  not  transmitted  to  the 
abdominal  walls.  Then,  the  foetus  beiug  so  moveable,  its  heart-beat,  as 
we  have  seen,  is  not  constant  at  any  one  point  even  when  alive;  and 
when  it  is  dead,  both  this  and  the  preceding  sign  fail  entirely. 


DISEASES    OF    THE    OVUM,  269 

Luckily,  it  is  not  the  same  with  ballottemeiit,  which,  in  cases  of  hydram- 
nion,  assumes  a  capital  importance.  It  is  in  fact  more  readily  per- 
ceived than  usual,  whether  practised  by  the  abdominal  or  by  the  vaginal 
method.  But  even  ballottement  may  sometimes  be  absent,  and  then  it 
is  only  by  a  careful  consideration  of  the  ensemble  of  the  symptoms  that  a 
conclusion  can  be  reached.  Usually,  however,  ballottement  is  easily 
appreciated,  and  by  that  sign,  with  fluctuation,  the  diagnosis  must  be 
established. 

2d.  The  Determination  between  twin  Pregnancy  and  Dropsy  of  the 
Amnion. — Both  cases  give  us  exaggerated  abdominal  enlargement;  but  in 
twin  pregnancy  there  is  hyper-enlargement  from  the  beginning  of  preg- 
nancy, while  in  hydramnion  the  first  months  of  pregnancy  pass  normally, 
and  the  rapid  and  excessive  distension  comes  only  later. 

In  twin  pregnancy,  also,  the  peculiar  shape  of  the  abdomen,  with  its 
increased  transverse  diameter,  and  the  presence  of  similar  foetal  parts  on 
opposite  sides  of  the  abdomen,  are  peculiar.  In  some  cases  the  belly  ap- 
pears to  be  divided  into  two  lobes  by  a  vertical  furrow,  especially  on  top, 
and  the  shape  is  characteristic. 

In  dropsy  of  the  amnion,  on  the  contrary,  the  shape  of  the  abdomen  is 
globular  and  more  regular.  The  uterus  is  uniformly  distended,  and  its 
vertical  diameter  is  almost  always  greater  than  is  its  transverse  measure- 
ment. 

Of  course,  twin  pregnancies  are  frequent  in  dropsy  of  the  amnion,  and 
it  must  be  recollected  that  these  signs  are  by  no  means  absolute. 

In  twin  pregnancies,  foetal  mobility  is  always  more  or  less  interfered 
with;  the  parts  that  are  a|)preciable  by  palpation  are  difficult  to  displace, 
whereas  all  authors  agree  that  the  size  of  abdominal  ballottement  is  ob- 
tained with  great  ease  in  hydramnion.  The  same  holds  true  for  vaginal 
ballottement,  Baudelocque  and  Levret  had  already  called  attention  to 
the  fact  that,  while  in  twin  pregnancy,  ballottement  is  incomplete  or  ab- 
sent, both  it  and  the  choc  en  retour  are  obtained  in  dropsy  of  the  am- 
nion with  great  facility.  Depaul  mentions  another  sign,  which  he  has 
been  the  first  and  only  one  to  recognize:  "On  examining  by  the  touch 
the  membranes  that  project  from  the  os,  he  has  twice  encountered  a  de- 
pression or  furrow  upon  them,  which  divides  the  amniotic  cyst  into  two 
parts;  he  was  thus  enabled  to  recognize  the  two  eggs  placed  side  by  side." 
The  supra-pubic  oedema,  regarded  by  some  as  of  value  in  the  diagnosis  of 
twin  pregnancy,  may  exist  in  cases  of  single  pregnancy  complicated  with 
dropsy  of  the  amnion;  nevertheless,  it  should  be  regarded  with  attention, 
for  a  number  of  cases  of  hydramnion  in  which  it  occurred  were  also  cases 
of  twins.  One  extremely  important  sign  for  the  diagnosis  of  dropsy  of 
the  amnion  is  fluctuation,  since  it  is  never  met  with  in  simple  twin  preg- 
nancies.- It  is  an  absolute  sign,  but  unfortunately  it  is  not  alwaj^s  pres- 
ent, and  when  it  is,  it  may  be  due  to  a  dropsy  other  than  that  of  the  am- 
nion, such  as  ascites. 


270  A    TREATISE    ON    OBSTETRICS. 

Auscultation  usually  enables  us  to  establish  the  diagnosis  of  twin  preg- 
nancy^ while  the  fcetal  heart-beats  are  obscure,  fugacious,  mobile,  or  even 
undetectable  in  cases  of  hydramnion. 

Auscultation  enables  us  in  twin  pregnancies  to  determine  the  existence 
at  two  different  points  on  the  abdomen  of  two  hearts  of  different  rhythms, 
and  between  which  a  point  can  be  found  where  the  two  hearts  are  heard 
with  a  minimum  of  intensity,  which  increases  as  you  proceed  in  either 
direction  towards  the  j)oints  of  maximum  intensity,  before  ascertained. 

The  diagnosis  is  far  more  difficult  when  the  foetus  is  dead;  for  we  are 
forced  to  rely  upon  palpation  alone,  and  the  modifications  of  the  uterus 
are  such  that  the  very  existence  of  pregnancy  may  be  a  matter  of  doubt. 
When  dropsy  of  the  amnion  has  complicated  twin  pregnancy,  as  has 
been  often  the  case,  the  latter  diagnosis  has  usually  not  been  made.  The 
dropsy  has  been  diagnosticated  early,  but  the  presence  of  a  second  foetus 
has  only  been  known  after  the  expulsion  of  the  first. 

We  think  that,  in  these  cases,  very  great  importance  is  to  be  attached 
to  the  supra-pubic  oedema;  it  does  indeed  exist  in  almost  every  case  of  twin 
pregnancy,  and  its  presence  should  always  awaken  a  suspicion  of  it  when 
dropsy  of  the  amnion  is  present. 

In  our  case,  where  there  was  both  twin  pregnancy  and  acute  hydram- 
nion, this  oedema  was  very  marked;  but  it  was  accompanied  by  a  general 
oedema  of  the  abdominal  wall,  and  of  the  genital  organs.  We  must  con- 
fess that  we  recognized  the  complication  without  thinking  of  the  existence 
of  twin  pregnancy,  Avhich  was  noticed  by  Dr.  Savornin,  whom  we  had 
called  in  to  see  the  patient. 

There  remains  for  us  to  consider  the  differential  diagnosis  between 
hydramnion  and  the  diseases  which  may  be  mistaken  for  it,  hydrorrhoeas, 
ascites,  ovarian  cysts,  and  vesicular  moles. 

It  would  seemingly  be  difficult  to  confound  hydrorrhoea  with  hydram- 
nion. Hydrorrhoea  is  characterized  by  a  fiow  of  watery  fluid,  occurring 
during  pregnancy,  and  usually  first  coming  on  during  the  night.  There 
is  generally,  after  the  first  outburst  of  fluid,  a  slower  and  continuous  loss. 
The  material  that  escapes  is  clear,  has  a  spermatic  odor,  and  stains  the 
linen.  The  flow  may  be  intermittent,  or  continuous,  or  come  drop  by 
drop.  As  a  rule,  there  is  no  pain,  though  JSTaegele,  Belfinger,  and  Ches- 
ton  have  recorded  cases  in  which  there  was.  Eare  before  the  fourth,  it 
is  usually  at  the  end  of  the  fifth  or  sixth  month  that  hydrorrhoea  occurs. 
Eecurring  generally  three  or  four  times  during  the  pregnancy,  hydror- 
rhoea may  persist  after  delivery,  and  replace  the  lochia  (Mauriceau,  Nae- 
gele,  Dubois).  The  os  remains  closed,  and  if  there  are  uterine  contrac- 
tions, they  are  regular  and  general.  If  nature  be  allowed  to  take  its 
course,  whatever  pain  may  be  present  generally  ceases,  and  the  pregnancy 
advances  normally.  The  fiow  of  false  water  does  not  diminish  the'  amount 
of  normal  liquor  amnii  present  at  birth,  nor  does  it  ever  contain  particles 


DISEASES    OF    THE    OVIDF.  271 

of  sebaceous  matter.  The  diagnosis  from  ascites  may  be  more  difficult, 
especially  if  the  ascites  complicates  pregnancy. 

In  simple  ascites,  besides  what  can  be  ascertained  by  palpation,  auscul- 
tation, and  the  vaginal  touch,  and  besides  the  absence  of  positive  signs  of 
pregnancy,  the  abdomen  is  peculiarly  flattened  and  widened  laterally,  and 
fluctuation  is  very  readily  perceived.  There  is  absolute  flatness  over  the 
lateral  portions  of  the  tumor,  with  an  intestinal  tympanitic  percussion 
note  over  the  superior,  anterior,  and  median  portions. 

This  flatness  varies  of  course  with  the  position  of  the  patient,  the  in- 
testines being  always  uppermost.  There  is  no  ballottement,  nor  can  foatal 
parts  be  felt,  ffidema  of  the  lower  portion  of  the  abdomen  is  often 
present,  and  finally  we  find  in  the  heart,  liver,  or  kidneys,  evidences  of 
the  lesion  that  has  caused  the  ascites. 

If  the  ascites  complicate  pregnancy,  the  diagnosis  is  more  difficult. 
The  fluctuation  is  more  readily  perceived  in  the  upper  than  in  the  lower 
part  of  the  abdomen,  and  the  fluid  is  displaced  according  to  the  woman's 
position. 

But  when  ascites  exists  with  hydramnion,  the  diagnosis  may  be  very 
difficult;  and  this  explains  the  errors  that  have  occurred. 

Robert  Lee  says:  "  The  diagnosis  of  hydramnion  with  ascites  is  very 
difficult.  Fluctuation  is  distinct,  but  it  does  not  tell  us  whether  the 
fluid  is  in  the  peritoneal  cavity,  or  in  the  amniotic  cavity,  or  in  both  places. 
The  presence  of  fluctuation,  therefore,  is  not  a  certain  evidence  of  the 
existence  of  the  affection,  and  the  only  way  to  arrive  at  a  precise  diagno- 
sis is  by  means  of  the  vaginal  touch.  This  enables  us  to  determine  whether 
the  uterus  has  undergone  changes  consecutive  to  impregnation,  and  also 
whether  there  is  an  excessive  amount  of  liquid  within  the  membranes  of 
the  ovum.  This  will  be  shown  by  the  almost  entire  effacement  of  the 
cervix,  by  the  development  of  the  body  of  the  uterus,  and  by  the  sensation 
of  vaginal  fluctuation  upon  abdominal  pei'cussion.''  In  ascites  complicated 
with  pregnancy,  Scarpa  has  observed  that  the  symptoms  are  different  from 
those  of  hydramnion.  "  The  large  collection  of  fluid  interferes  with  our 
recognition  of  the  regular  form  of  the  fundus  and  body  of  the  gravid 
uterus.  The  urine  is  diminished  and  lactescent,  thirst  is  constant.  There 
is  obscure  fluctuation  in  the  hypogastric  region,  more  distinctly  percepti- 
ble in  the  hypochondrium,  between  the  edge  of  the  rectus  muscle,  and 
the  false  ribs.-" 

Scarpa  thereupon  maintains  that  puncture  of  the  pregnant  uterus  is 
not  as  serious  an  operation  as  has  been  maintained  by  Chambon,  and  cites 
the  observations  of  Bohn  (pregnancy  mistaken  for  ascites),  of  Camper, 
Langius,  and  especially  Nesse:  (Dropsy  of  the  amnion  at  the  flfth  month. 
Paracentesis  at  the  linea  alba,  midway  between  umbilicus  and  pubes. 
Twins  born,  that  died  soon  after.  A  metrorrhagia,  not  followed  by  serious 
results,  was  all  that  ensued.) 


272  A    TREATISE    ON"    OBSTETRICS. 

Ovarian  Cysts. — Tliougli  usually  easy  to  distinguisli  from  dropsy  of 
the  amnion,  it  is  not  always  so,  as  the  cases  of  Boddy,  Hiod,  Hunt,  and 
Kidd  would  show. 

The  recognition  of  the  certain  signs  of  pregnancy  only  can  prevent 
error.  The  menses  may  be  absent  in  both  cases,  and  there  are  on  record 
cases  of  inflammation  of  ovarian  cysts  in  which  the  accumulation  of  liquid 
has  taken  place,  almost  as  quickly  as  in  dropsy  of  the  amnion.  In  both 
cases  great  pain  accompanies  the  abdominal  enlargement.  But  the  pro- 
gressive growth  of  hydramnion  is  replaced  in  the  case  of  the  cyst  by  sud- 
den enlargements  at  the  menstrual  epochs,  with  slower  and  more  contm- 
uous  progress  between  them.  Besides  this  the  tumor  in  ovarian  cyst 
begins  on  one  side,  and  the  uterus  is  displased  in  the  opposite  direction. 
Finally,  we  may  detect  the  modifications  in  the  neck  and  lower  part  of 
the  uterus,  and  the  three  certain  signs  of  pregnancy,  ballottement,  the 
foetal  heart  and  foetal  motion. 

Sometimes,  as  in  one  of  our  cases,  these  signs  fail  us,  and  we  must 
have  recourse  to  other  means  of  diagnosis.  Fluctuation  is  said  to  be  more 
manifest  in  hydramnion  than  in  ovarian  cyst;  but  in  certain  cases  it  may 
be  wanting.  But  there  is  one  sign  which  is  pathognomonic,  and  which 
was  present  in  our  second  case. 

In  this  case  all  the  certain  signs  of  pregnancy  were  absent,  and  rectal 
and  vaginal  touch  gave  us  no  aid.  Palpation  was  difficult  from  the  ex- 
treme sensibility,  and  the  oedema  of  the  abdominal  walls  permitted  only 
the  perception  of  a  false  fluctuation.  Only  the  suppression  of  the  menses, 
and  the  results  of  an  anterior  examination  made  by  a  physician,  caused 
us  to  suspect  pregnancy.  But  at  the  second  examination  I  could  feel  in 
the  abdomen  intermittent  contractions,  and  the  uterus  is  the  only  organ 
which  could  give  rise  to  any  such  sensation. 

G-.  H.  Kidd,  discussing  the  diagnosis  between  dropsy  of  the  amnion 
and  ovarian  cysts,  says:  "  The  encysted  liquid  may  be  a  distended  blad- 
der, a  dropsy  of  the  amnion,  an  ovarian  cyst,  or  a  pregnancy  complicated 
by  an  ovarian  cyst.  The  absence  of  urine  on  catheterism,  disposes  of  the 
first;  the  state  of  the  nipples,  and  the  presence  of  a  floating  body  in  the 
abdomen,  shows  the  presence  of  a  foetus;  while  with  ovarian  cysts,  the 
uterus  can  always  be  felt  in  the  true  pelvis."  Both  Boddy  and  Hiod  punc- 
tured, in  cases  of  hydramnion,  believing  them  to  be  ovarian  cysts,  and 
Kill  did  the  same,  and  delivered  the  woman  of  twins,  in  a  case  of  hydram- 
nion, which  he  took  to  be  pregnancy  complicated  with  ovarian  cyst.  De- 
paul,  in  connection  with  his  case  of  extra-uterine  peritoneal  pregnancy 
with  hydramnion,  says:  "  This  is  a  rare,  if  not  unique  example,  of  dropsy 
of  the  amnion,  complicating  an  extra-uterine  pregnancy.  The  size  of 
the  abdomen  prevented  palpation  of  the  foetal  parts,  and  there  was  a 
tense,  rounded,  and  fluctuating  pouch  instead  of  the  ordinary  lumpy 
tumor.     I^he  cervix  was  in  its  usual  place,  which  is  rare  in  extra-uterine 


DISEASES   OF   TilE  OVUM.  273 

pregnancy.  The  patent  orifice  permitted  me  to  reach  the  fundus  uteii 
witli  my  finger;  but,  instead  of  enlightening  me,  it  simply  made  me  sus- 
pect an  obliteration  of  the  internal  os/' 

There  remains  to  be  considered  the  diagnosis  from  the  hydatid  mole. 
It  seems  impossible  to  mistake  hydramnion  for  it.  The  only  symptom 
sometimes  found  in  the  vesicular  mole,  that  is  analogous  to  any  sign  of 
dropsy  of  the  amnion,  is  the  rapid  development  of  the  abdomen,  and  its 
want  of  proportion  to  the  stage  of  pregnancy.  But  the  constant  presence 
of  alternating  losses  of  reddish  and  watery  fluid,  the  hemorrhage  which 
always  accompanies,  precedes,  or  follows  the  termination  of  the  disease, 
and  the  occasional  passage  of  vesicles,  should  suffice  to  remove  all  doubts. 

Pathological  Anatomy. — Most  authors  regard  hydramnion  as  a  disease 
of  the  foetus  or  its  membranes,  and  it  is  there  that  we  should  look  for  the 
cause  of  the  affection.  But  in  some  cases  the  examination  of  these  has 
been  neglected;  and  in  as  many  more  it  has  been  made  without  finding 
anything.  In  a  third  set  of  cases,  lesions  have  been  found,  but  they 
were  not  characteristic.  Three  varieties  of  lesion  seem,  however,  to  be 
specially  constant:  1st.  Those  of  a  supposedly  inflammatory  nature.  2d. 
Foetal  malformations.  3d.  Lesions  of  the  uterus,  or  tumors  of  various 
kinds. 

1st.  Lesions  of  an  inflammatory  Nature. — These  have  usually  con- 
sisted in  thickening  of  the  membranes,  with  more  or  less  marked  capillary 
injection,  a  varying  red  color,  and  false  membranes,  either  on  the  sur- 
face of  the  amnion,  or  on  the  foetal  surface,  and  in  the  thickness  of  the 
placenta. 

Thus  Dubois  and  Desormeaux:  thickening  and  hypertrophy  of  both 
placentas,  which  were  united. 

Godefroy:  membranous  plaques  upon  the  internal  surface  of  the  pla- 
centa and  the  membranes. 

Oulmont:  infiltration  of  edges  of  the  placenta,  and  oedema  of  the  cord. 

Provost:  one  placenta  and  two  amniotic  cavities  for  three  foetuses, 
the  two  amnii  being  enclosed  in  a  common  covering.  One  cord  was  oede- 
matous. 

Ollivier  (d' Angers) :  thickening  of  the  membranes,  which  were  white  and 
opaque,  like  parchment.     Injected  vessels. 

Mercier:  the  same  changes,  with  a  species  of  false  membrane.  Sen- 
tex:  same,  placenta  livid. 

Eobert  Lee:  placenta  soft  in  parts,  and  dark  in  color,  looking  like  the 
lung  in  cases  of  pulmonary  apoplexy. 

Toogood:  adhesions  of  placenta.     Atthill:  same. 

D^Outrepont:  cartilaginous  and  hepatic  degeneration  of  the  placental 
tissue. 

Hildebrand  t :  fibro-myxoma  of  placenta. 
•  Hunter:  hypertrophy  of  placenta. 
Vol.  II.— 18. 


274  A    TREATISE    OW    OBSTETRICS.^ 

Valenta:  maternal  and  foetal  syphilis. 

Scdillot:  empliysema  of  foetus. 

Lee,  Obs.  I.:  Foetal  ascites,  malformations  of  lungs.  Obs.  VI. :  Foetal 
ascites. 

Bourgarel:  Foetal  ascites.     Pemphigus.     Onyxia,  congested  placenta. 

Liegener,  Obs.  XII. :  Cord  soft  and  short.  Obs.  XIV. :  Cord  yery 
cedematous;  pemphigus;  liver  much  developed. 

2d.  Monstrosities. — Pietro  Lusana:  anencephalus. 

Siebold:  hydrocephalus.     Cystic  degeneration  of  kidneys. 

Battson:  hydrocephalus.  Infiltration  of  skin  and  subcutaneous  cellu- 
lar tissue.  Anchylosis  of  articulations  of  hands  and  feet.  Cystic  degen- 
eration of  the  cord. 

Thomas:  exaggerated  development  of  the  head. 

Jungmann:  premature  ossification  of  the  head. 

Lumpe:  umbilical  hernia  into  cord.  Hypertrophy  of  the  skin  of  the 
head.  Club-foot. 

Zacharias,  Lawrence,  and  West:  encephalocele. 

Griffith:  tumor  covered  with  the  normal  scalp,  filled  with  liquid  and 
cerebral  debris. 

Werner:  thin  cord  with  bands.     Double  hair-lip.    Absence  of  left  lung. 

Biihelen:  hydro  thorax. 

Loschner:  double  monstrosity.  One  child  normal,  the  other  atrophied. 
Adhesions  of  both  lungs. 

Frankenhauser:  obliteration  of  the  urethra;  oedema  of  cord  and  foetus. 

Hildebrandt:  hydatid  mole. 

Eausch,  Werner,  Parien:  faults  in  the  cord.     Placental  atrophy. 

Lee:  hydrocephalus. 

Dill:  anencephalus. 

Liegener:  double  hare-lip. 

Gueniot  (Guillemet):  anencephalus. 

Polaillon.(Guillemet):  clubbed  hands,  imperforate  anus. 

Pinard:  two  cases  of  anencephalus. 

3d.    Tumors. — Keating:  uterine  fibroid.     Gueniot:  same. 

Neuschler:  uterine  tumor. 

Pfannkuch:  carcinoma  uteri. 

These  are  the  chief  changes;  and  we'  shall  see  tnat  it  is  especially  in 
the  acute  cases  of  hydramnion  that  the  lesions  considered  inflammatory 
have  been  noticed. 

The  liquor  amnii  itself  is  generally  normal;  a  few  authors  have  found 
it  fetid,  and  reddish  or  greenish  in  color. 

We,  therefore,  conclude  that  pathological  anatomy  gives  us  no  certain 
data;  for  all  the  above  lesions  have  often  been  found  in  cases  in  which 
there  was  not  the  least  trace  of  dropsy  of  the  amnion. 

Prognosis. — Most  authorities  consider  dropsy  of  the  amnion  a  serious 


DISEASES    OF    THE    OVUM.  275 

cortiplication  for  tlie  foetus,  while  it  rarely  compromises  the  health  or  life 
of  the  mother.  This,  however,  is  only  true  up  to  a  certain  point.  In 
the  slowly  progressive  form,  but  little  discomfort  is  experienced  by  the 
woman;  but  in  acute  hydramnion  the  distress  is  very  great  indeed,  and 
the  prognosis  for  the  mother  much  more  grave.  We  may,  in  this  respect, 
divide  dropsy  of  the  amnion  into  three  degrees. 

In  the  first  degree,  the  excess  of  fluid  accumulates  very  slowly,  and  the 
woman  only  suffers  from  discomfort  and  an  increase  of  the  usual  malaise 
of  pregnancy.  As  a  rule  no  diagnosis  is  made,  and  it  is  only  at  the  mo- 
ment of  delivery  that  the  excessive  amount  of  liquor  amnii  strikes  the  ac- 
coucheur.    Every  obstetrician  must  have  met  such  cases. 

In  the  second  degree,  there  is  more  fluid,  and  the  uterus  reacts  more 
strongly.  Besides  the  ordinary  accidents  of  dropsy  of  the  amnion,  uterine 
contractions  causing  premature  rupture  of  the  membranes,  and  expulsion 
of  the  foetus,  are  liable  to  occur. 

In  the  third  degree,  the  same  premature  contractions  exist,  but  they  are 
not  sufficient  to  determine  labor,  at  all  events  for  a  certain  time.  The 
patients  are  very  sick,  and  are  exposed  to  the  various  accidents  that  we 
have  noticed,  so  that  active  interference  is  sometimes  required.  It  is 
especially  in  cases  where  hydramnion  occurs  with  phenomena  that  have 
caused  errors  of  diagnosis  (ascites,  ovarian  cysts,  etc.),  that  active  meas- 
ures have  been  taken. 

This  is  by  no  means  the  case  in  the  fourth  set  of  cases,  which  we  have 
called  acute  hydramnion.  In  these  cases,  the  diagnosis  is  made.  The 
rapidity  of  its  evolution,  and  the  serious  nature  of  the  accidents  that  may 
occur,  can  in  a  short  time  compromise  the  life  of  the  woman,  and  neces- 
sitate immediate  intervention. 

Here  the  enormous  distension  of  the  uterus,  out  of  all  proportion  to  the 
presumed  stage  of  the  pregnancy,  the  excessive  pain,  the  vomiting,  the 
emaciation,  the  intense  fever,  the  circulatory  and  respiratory  troubles, 
the  asphyxias,  oedemas,  eclampsias,  and  even  abortions,  give  us  a  very 
different  form  of  the  disease. 

In  regard  to  delivery  itself,  let  us  note  the  frequency  of  faulty  presen- 
tation, and  the  occurrence  of  procidentia  and  uterine  inertia,  either  dur- 
ing labor  or  at  delivery,  and  the  hemorrhages.  The  following  table  of 
observations,  deduced  from  80  cases  collected  from  literature,  show  the 
result  and  the  presentations: 


Child  dead  without  sign. 

Abortion, 

Head,  with  prolapse  of  hand. 

Vertex,  .... 

Buttocks  and  feet,  . 

Slioulders, 


] 
1 

1 
46 

9 
20 


Face,       ..........  2 


276  _  A   TREATISE   ON    OBSTETRICS. 

MacClintock,  out  of  31  cases:  presentation  of  the  vertex,  20;  breech^ 
9;  foot,  2. 

We  understand  to  wha,t  extent  liydramnios  complicates  confinement, 
by  the  fact  of  the  abnormal  presentations,  and  these  figures  only  include 
single  pregnancies.  As  for  the  hemorrhages  which  accompany  or  follow 
delivery,  and  which  are  due  to  uterine  inertia,  all  the  authors  have  noticed 
them  in  the  cases  of  exaggerated  distension  of  the  uterus,  either  by  a 
very  large  fcetus,  or  in  cases  of  twin  pregnancy.  It  is  not  extraordinary 
to  see  them  produced  in  cases  of  liydramnios,  or  this  exaggerated  disten- 
sion of  the  uterus  produced  in  an  extreme  degree.  We  confine  ourselves, 
with  Sallinger,  to  citing  the  cases  of  Senlen,  Valenta,  Schmatz,  Lumpe, 
Gueniot,  Martin,  Hansen,  Klink,  Harlin,  Parieu,  Rigler,  Quadrat,  Huber, 
Keating. 

As  regards  the  child,  the  prognosis  is  still  more  grave,  and  though  in 
the  observations  of  Liegener,  out  of  40,  there  were  31  infants  living,  we 
do  not  hesitate  to  say  that  hydramnios  is  one  of  the  diseases  which  most 
compromise  the  existence  of  the  fcetus.  In  many  cases,  indeed,  it  is  ex- 
pelled dead  from  the  uterus  (we  may  ask  if  the  death  of  the  foetus  had 
not  been  the  determining  cause  of  the  malady) ;  in  others,  more  frequent- 
ly, it  dies  shortly  after  birth.  We  have  seen  that  often  delivery  occurs 
before  term. 

In  addition,  the  frequency  of  multiple  pregnancy,  and  of  dangerous  pres- 
entations complicating  the  confinement,  put  the  infant  in  unfavorable 
conditions  and  render  the  prognosis  more  grave. 

Finally,  we  recall  the  frequency  of  monstrosities  in  cases  of  hydramnios, 
and  the  connection  between  syphilis  and  hydramnios. 

MacClintock  considered  hydramnios  as  one  of  the  morbid  conditions 
very  common  in  abortion,  and  he  regards  it  as  a  frequent  cause  of  the 
premature  death  and  expulsion  of  the  embryo.  Out  of  83  cases  of  hy- 
dramnios noted  by  him,  one  terminated  by  abortion  at  five  months, 
one  at  six  months,  ten  resulted  in  premature  delivery.  In  21  cases  the  child 
appeared  to  have  attained  the  normal  term,  and  he  says  "  there  is  good 
reason  to  think  that  some  cases  of  the  disease  in  question  are  a  disease  of 
the  ovum  and  not  of  the  uterus.  The  abnormal  excess  of  the  amniotic 
fluid,  or  perhaps  the  morbid  action  of  which  it  is  the  result,  appears 
very  unfavorable  to  the  foetus.  Thus,  9  of  the  children  were  still-born, 
of  which  5  were  putrid,  and  10  born  alive  died  some  hours  after  birth. 
This  was  oftener  the  case  among  the  girls  than  the  boys  (25  girls  to  8 
boys). 

Treatment. — In  many  cases  hydramnios  passes  almost  unnoticed.  The 
indications  are  confined  to  combating  the  ordinary  diseases  of  pregnancy, 
without  the  necessity  of  special  treatment.  At  other  times,  on  the  con- 
trary, the  conditions  are  exceptionally  serious,  and  then  intervention  is 
necessary^  which  is  either  medical  or  obstetrical. 


DISEASES    OF    THE    OVUM.  277 

Medical  treatment  is  in  general  of  little  nse.  All  forms  designed  to 
combat  tlie  "  dropsy/'  diuretics,  purgatives,  sulphate  of  quinine  and 
opium,  have  been  employed.  All  seem  to  have  failed.  Phlebotomy  has, 
at  times,  seemed  to  succeed. 

Modern  works  on  the  composition  of  the  blood  in  pregnant  women 
have,  however,  rejected  bleeding  in  the  treatment  of  pregnancy.  We 
believe  that  the  writers  have  gone  too  far  in  this  regard.  Of  course  we 
do  not  believe  in  the  ancient  method,  in  which  bleeding  was  practised  to 
an  incredible  extent,  as  in  the  observation  of  Mauriceau,  where  a  woman 
had  been  bled  73  times  during  her  pregnancy;  but  we  believe  in  certain 
cases  bleeding  has  its  advantages;  and,  without  speaking  here  of  bleeding 
employed  as  preventive  of  eclampsia,  we  have  seen  (as  interne  at  thp 
Charite)  Beau,  who  certainly  was  not  partial  to  bleeding,  practise  it  in  a 
number  of  pregnant  women,  and  never  have  there  been  other  than  good 
results.  Our  teachers  did  not  reject  it  utterly,  and  P.  Dubois,  Cazeaux 
and  Jacquemier,  advised  it  in  certain  cases,  where  women  considered  as 
plethoric  were  threatened  with  abortion;  and  they  have  cited  cases  where, 
thanks  to  a  rapid  and  moderate  depletion  of  the  vascular  system,  the  preg- 
nancy has  continued  its  course. 

Surgical  Treatment. — On  account  of  the  serious  condition,  and  the 
threatened  life  of  the  mother,  it  is  necessary  to  interfere.  Nature,  indeed, 
seems  to  indicate  the  means,  in  provoking  premature  contractions,  which 
induce  rupture  of  the  membranes  and  interruption  of  the  pregnancy. 
Whatever  Guillemet  may  say,  all  obstetricians  agree  that  it  is  by  the  cer- 
vix that  the  foetal  sac  must  be  penetrated,  and  if  there  are  some  instances 
where  puncture  of  the  uterus  has  been  done,  it  was  due  to  an  error  of  di- 
agnosis, and,  though  Scarpa,  Camper,  Noel  Desmarais,  etc.,  have  cited 
cases  where  a  puncture  has  not  been  followed  by  accident,  and  certainly 
by  the  woman's  recovery,  it  should  be  rejected.  Consequently  rupture 
of  the  membranes  should  be  adhered  to.  But  here,  still,  different  ques- 
tions are  presented:  1st.  The  point  of  perforation.  2.  The  moment  for 
intervention. 

1st.  Point  to  rupture  the  Membrane. — It  is  seen  at  once  that  there 
is  no  time  for  hesitation.  The  cervix  being  generally  partly  open 
from  the  premature  contraction,  the  membranes  rush  into  the  inter- 
nal OS.  Nothing  is  simpler  than  to  perforate  them  with  a  stylet,  sound 
or  trocar.  But  this  rupture  is  not  always  without  difficulties.  At  the 
moment  of  the  rupture,  the  liquid,  by  reason  of  its  great  quantity,  rushes 
out  in  torrents,  tends  to  enlarge  the  opening  in  the  membranes,  and  so 
to  sweep  along  the  foetal  membrane,  cord  and  foetus.  On  the  other  hand, 
the  uterus,  in  consequence  of  the  rapid  evacuation  of  the  liquid,  tends  to 
contract  with  a  rapidity  dependent  on  the  quantity  of  liquid  evacuated. 
Eurther,  there  is  the  possibility  of  detaching  the  placenta,  at  one  or  many 
points,    and   of    hemorrhages.     Finally,  this   rapid   evacuation   induces 


278  A    TREATISE    OTST    OBSTETEICS. 

symptoms  analogous  to  those  seen  when  the  pleural  or  abdominal  cayities 
are  emptied  too  rapidly,  in  pleurisy,  hydrothorax  or  ascites,  namely  syn- 
cope. Different  methods  have  been  advised  for  this  end.  The  first, 
which  is  an  absolute  rule  when  one  has  to  puncture  the  membranes  for 
hydramnios,  or  for  narrowing  of  the  pelvis — that  is, when  the  fcetus  is  move- 
able beyond  the  superior  strait,  or  in  the  excavation — is  never  to  rupture 
the  membranes  except  in  an  interval  of  contraction,  the  woman  lying  with 
the  buttocks  raised,  so  as  to  increase  the  inclination  of  the  pelvis  back- 
ward. The  use  of  the  stylet  or  trocar,  to  make  only  a  little  opening,  has 
been  advised,  but  the  liquid  increases  the  size  of  the  opening. 

Tarnier,  according  to  G-uillemet,  operates  as  follows:  he  places  the  in- 
dex finger  on  the  bulging  membrane;  at  the  same  time  the  other  fingers, 
closed  in  the  palm  of  the  hand,  are  applied  as  exactly  as  possible  over  the 
vulvar  orifice  at  the  movement  of  contraction.  The  membranes  are  rup- 
tured by  the  nail  of  the  index  finger.  At  this  moment,  instead  of  with- 
drawing the  hand,  it  is  pushed  against  the  vulvar  orifice.  In  this  man- 
ner a  nearly  perfect  prevention  of  the  issue  of  fiuid  is  obtained.  This 
procedure  does  not  seem  to  us  to  be  likely  to  be  followed  by  the  hoped- 
for  success;  for  if  it  prevents  the  escape  of  fluid  from  the  vagina,  it 
does  not  prevent  the  rent  enlarging  itself.  The  liquid,  it  is  true,  can 
not  flow  away  externally,  but  it  can  flow  into  the  vagina,  and  it  will  do 
so  the  more  according  as  we  have  chosen  the  period  of  uterine  contrac- 
tion to  rupture  the  membrane. 

We  prefer  then  to  choose  the  interval  of  uterine  contractions.  It  will 
be  a  little  more  difficult  to  rupture  the  membranes,  but  the  liquid  will 
escape  more  slowly,  there  will  be  less  chance  of  the  prolapse  of  the  mem- 
bers, and  of  premature  detachment  of  the  placenta.  Impressed  by 
these  inconveniences,  Meissner  has  invented  a  curved  trocar,  with  which 
he  advises  the  induction  of  premature  labor,  to  perforate  the  membranes 
at  the  middle  part,  or  above  the  ovum,  to  preserve  also  a  certain  quantity 
of  fluid,  and  to  place  the  foetus  in  more  favorable  conditions.  This  may 
be  resorted  to  in  cases  of  hydramnios,  though  the  results  hoped  for  by 
Meissner  do  not  seem  to  have  been  obtained. 

2d.  Moment  of  Intervention. — Here  we  are  unable  to  lay  down  precise 
rules,  and  from  the  gravity  of  the  symptoms  only  can  we  determine  the 
moment  of  intervention.  In  slight  cases,  wait.  The  uneasiness  felt  by 
the  woman  is  not  sufficient  to  endanger  her  life,  and  consequently  the 
obstetrician  should  act  expectantly.  On  the  contrary,  in  the  more  serious 
cases,  it  is  necessary  to  interfere,  but  here  still  the  indications  vary  with 
the  case.  Indeed,  ordinarily,  hydramnios  comes  on  in  an  advanced  state 
of  pregnancy,  its  course  is  slowly  progressive,  and  it  is  only  at  certain 
times,  that  it  produces  serious  symptoms.  Tbe  obstetrician  should  follow 
the  development  of  the  disease;  he  will  gain  thus  the  greatest  amount  of 
time,  and  it  is  rare  that  he  will  have  to  interfere  before  the  seventh  or 


DISEASES    OF    THE    OVUM. 


279 


eightli  month.  It  is,  therefore,  a  premature  delivery  that  he  causes.  While 
wholly  protecting  the  interests  of  the  mother,  he  regards  the  viability 
of  the  child,  and  so  he  should  retard  the  moment  of  intervention  as  long  as 
possible,  to  allow  the  pregnancy  to  reach  as  nearly  as  possible  normal  term. 
In  acting  thus,  we  give  to  the  foetus  more  chance  of  surviving,  without 
compromising  the  life  of  the  mother.  If  the  symptoms  supervene  earlier, 
if  the  phenomena  experienced  by  the  mother  are  of  a  nature  to  endanger 
her  life,  the  obstetrician  need  not  hesitate,  and  he  should  interfere  prompt- 
ly and  rapidly  in  her  interest — we  will  say,  also,  in  the  interest  of  the  foetus. 
In  so  acting,  Guillemet  says,  rightly,  we  avoid  for  the  mother  excessive 
pain  and  serious  conditions,  which  have  sometimes  induced  death,  as  in 
the  observations  of  Lee;  and,  on  the  other  hand,  we  eliminate  the  causes 
of  death  for  the  infant,  for,  in  nearly  all  observations,  the  signs  of  life 
in  the  infant  have  only  disappeared  when  the  symptoms  were  protracted 
a  long  time. 

In  cases  of  acute  hydramnios,  the  procedure  should  be  different.  The 
rapidity  with  which  the  symptoms  develop,  their  intensity,  the  serious 
phenomena  which  they  cause  in  the  mother,  require  an  early  intervention, 
and  necessitate,  not  only  premature  labor,  but,  indeed,  the  induction  of 
abortion.  The  uterus  tends  itself  to  expel  the  product  of  conception,  and 
it  is  in  these  cases  especially  that  premature  contractions  occur.  But 
these  contractions  are  most  often  insufficient  to  determine  labor,  and  they 
only  augment  the  suffering.  It  is  necessary,  therefore,  to  interfere,  and 
induce  abortion  without  hesitation.  Of  course  the  responsibility  of  the 
obstetrician  is  great,  and  interruption  of  pregnancy  at  a  time  when  the 
foetus  is  not  viable  is  always  an  operation  not  to  be  undertaken  unless 
it  is  absolutely  necessary;  but  we  believe  that  in  these  cases  to  hesitate  is 
not  allowable,  and  that  on  account  of  the  chance  of  the  mothers  death, 
the  obstetrician  should  practise  abortion  conscientiously,  which,  if  it  end 
fatally  to  the  infant,  allows  the  mother  almost  every  chance  of  recovery. 

It  is  seen  by  our  observation  that  we  did  not  hesitate.  The  cure  of  the 
mother  justifies  our  intervention,  and,  should  we  again  be  thrown  with 
such  a  case,  we  should  have  recourse  to  abortion.  By  it,  indeed,  the  foetus 
is  surely  sacrificed,  but  the  mother  is  almost  certainly  saved,  and  we  believe 
that  between  the  saving  of  a  woman  who  has  other  children,  and  the  saving, 
more  or  less  problematical,  of  a  foetus  subject  to  all  the  unfavorable  circum- 
stances in  which  it  is  placed  by  the  hydramnios  alone,  not  only  is  abortion 
authorized,  but  indicated;  and  that  the  obstetrician  who  hesitates  thus  to 
intervene  in  this  case  fails  professionally,  and  to  his  own  sense  of  duty. 

Various  Alterations  of  the  A^nniotic  Fluid. 

In  dropsy  of  the  amnion,  the  amniotic  fluid  is  altered  in  its  quantity, 
and  in  its  quality  as  well,  and  these  alterations  are  of  quite  different  kinds. 
Some  are  compatible  Avith  the  life  of  the  foetus;  the  others  conduce  to 


280  A    TREATISE    ON    OBSTETRICS. 

its  death.  At  the  beginnmg  of  pregnancy,  limpid,  transparent,  colorless, 
of  a  density  less  than  water,  the  amniotic  fluid  later  should  become  unctu- 
ous, a  little  thick,  and  especially  remarkable  for  the  presence  of  little 
whitish  caseous  lumps,  which  are  similar  to  the  sebaceous  matter  cover- 
ing the  body  of  the  foetus.  Most  of  the  foreign  substances  absorbed  by 
the  mother  are  there  met  with.  We  cite,  among  others,  the  case  of 
Levret,  who  has  seen  the  amniotic  fluid  whiten  copper  in  a  woman  who 
was  undergoing  mercurial  treatment.  A  case  has  been  cited  where  the 
odor  of  camphor,  absorbed  by  the  mother,  was  noticeable.  Everyone 
knows  the  case  of  Stoltz,  who  has  seen  a  child,  born  living,  where 
the  amniotic  fluid  gave  an  offensive  odor  of  putrefying  tobacco;  the 
mother  worked  in  tobacco.  The  amniotic  fluid  may  acquire  irritating 
properties,  as  in  the  case  of  ISTaegele,  where  there  was  found  a  kind  of  mac- 
eration of  the  foetal  epidermis.  The  child,  though  born  feeble,  recovered 
perfectly,  and  was  in  perfect  condition  at  the  end  of  the  fifth  day,  after 
shedding  its  epidermis. 

There  is  one  form  of  alteration  which  is  much  more  frequent — that 
which  is  due  to  the  presence  of  meconium  in  the  liquor  amnii.  Nor- 
mally, in  cases  gf  breech  presentation,  the  meconium  gives  to  the  fluid  a 
green  tinge,  more  or  less  pronounced  according  to  the  quantity  that  has 
been  mixed.  In  some  cases  the  fluid  is  thin;  in  others  it  is  much  thick- 
ened and  sticky;  and  if  one  does  not  consider  the  escape  of  the  greenish 
fluid  as  evidence  of  the  death  of  the  foetus,  as  the  older  obstetricians 
thought,  it  indicates  at  least  an  action  on  this  little  being,  by  compression 
of  the  cord  or  otherwise,  prolonged  labor,  etc.  However,  this  sign  is  not 
certain,  and  it  is  not  rare  to  see  the  child  born  alive  after  abundant  escape 
of  very  dark  liquor  amnii.  One  can  say,  in  a  general  way,  that  the  de- 
gree of  intensity  of  these  changes,  and  the  greater  or  lesser  fluidity,  are 
proportional  with  the  perfect  health  of  the  foetus,  though  the  foetus  may 
be  born  alive  with  very  thick  and  fetid  liquor  amnii.  Auscultation  only 
can  decide  as  to  the  beating  of  the  heart;  its  perfect  regularity  and  nor- 
mal force  has  completely  reassured  us  in  a  case  where  at  first  one  might 
have  some  fear. 

Concerning  the  alterations  which  are  consecutive  to  the  death  of  the 
foetus,  Lempereur  describes  three  degrees.  In  the  first,  there  is  a  solu- 
tion of  the  foetus;  in  the  second,  a  mummification;  in  the  third,  macera- 
tion; the  other  alterations  are  only  produced  after  the  escape  of  the  fluid, 
and  after  the  entrance  of  air  into  the  sac.  To  these  three  periods,  differ- 
ent states  of  the  amniotic  fluid  correspond. 

In  the  first  (solution),  the  fluid  is  no  longer  clear,  transparent,  limpid 
and  pale  yellow,  but  sometimes  simply  dirty  and  thickened,  sometimes 
milky,  like  an  emulsion,  according  to  the  quantity  of  organic  elements 
dissolved.  This  fact  is  mentioned  by  the  older  obstetricians,  as  Mauri- 
ceau,  Puzos,  Bischoff,  Martin,  and  others. 


DISEASES    OF    THE    OVUM.  281 

In  the  second  (mummification),  tlie  liquid  is  diminished,  still  thicker, 
granular,  purulent,  or  rather,  as  if  mixed  with  a  clayey  earth.  At  a 
more  advanced  degree  it  disappears,  leaving  on  the  embryo  a  grayish 
oily  sediment  analogous  to  the  deposit  of  oyerflowed  water. 

In  the  third  (maceration),  the  liquid  is  altered  according  to  the  state 
of  the  foetus.  This  period  is  characterized  by  the  oedematous  infiltration 
of  the  foetal  tissue  with  a  bloody  serum,  complete  inhibition  of  the  soft 
parts  with  their  softening  and  shrinking,  and  raising  of  the  epidermis  in 
phlyctenulaj,  in  vast  blisters.  It  is  this  escaped  liquid  which  gives  to  the 
liquor  amnii  its  special  characteristics.  It  is  thin,  red  and  bloody,  more 
or  less  tliick.  With  this  condition  of  the  fluid  the  foetus  is  dead.  This  is 
verified  by  clinical  observation.  These  changes,  however,  are  not  always 
found  in  cases  of  foetal  death. 

Lempereur  has  noted  many  cases,  where  on  rupture  of  the  membranes, 
a  clear  and  quite  transparent  liquid  escaped.  This  is  due  to  the  fact 
that,  at  the  moment  of  rupture,  the  buUte  are  intact,  and  it  proves  that 
the  liquid  which  they  contain  alters  the  amniotic  fluid  after  their  rupture. 

Amniotic  Cords. 

These  amniotic  bands  are  not  as  rare  as  might  be  supposed,  for  Klotz 
was  able,  in  1869,  to  collect  34  cases.  Montgomery,  who  had  already  ob- 
served them,  considered  them  as  organized  lymph;  Simpson,  as  the  result 
of  local  inflammation  of  the  skin  of  the  foetus;  Simonart,  as  due  to  ulcer- 
ation of  the  skin  of  the  foetus,  and  to  inflammation  of  the  amnion}  Gurlt, 
as  prolongations,  not  detached,  from  the  skin  of  the  foetus;  Scanzoni,  as 
exudations  from  the  internal  surface  of  the  uterus,  and  penetrating  across 
the  amnion;  G-.  Braiin  considers  them  as  the  folds  of  the  amnion.  Very 
probably  they  are  not  inflammatory  products,  but  adhesions,  partly  meta- 
morphosed, of  the  amnion  to  the  foetus.  Spiegelberg  proclaims  that  they 
should  be  considered  as  due,  sometimes,  to  a  very  early  inflammation  of 
the  amnion  having  induced  an  adhesion  to  the  skin  of  the  foetus;  some- 
times, more  rarely,  as  an  arrest  of  development,  an  abnormal  fold  of  the 
amnion,  but  he  rightly  remarks  that,  up  to  the  present  time,  no  one  has 
discovered  vessels  in  the  amnion,  hence  its  inflammation  is  more  than 
problematical,  and  he  supposes,  with  Braiin,  that  they  are  due  to  abnormal 
folds  of  the  amnion,  or  to  an  incomplete  or  too  late  separation  from  the 
fcetus,  produced  by  an  unknown  cause,  perhaps  by  insuflicient  or  tardy 
secretion  of  the  liquor  amnii.  As  a  consequence,  arrest  of  development, 
sometimes  fissures  in  the  foetus,  the  liquor  amnii  developing  and  distend- 
ing the  amniotic  sac.  These  adhering  points  are  lengthened  in  bands, 
which,  by  the  constriction  they  exercise  on  the  foetus,  cause  malforma- 
tions and  spontaneous  amputations.  One  sometimes  finds  the  fcetus  thus 
malformed,  and  at  points  corresponding  to  the  constriction,  free  ends. 


282 


A   TREATISE   ON    OBSTETEIOS. 


detached  bands,  or  sometimes  only  cicatrices.  Finally  tlie  bands  may  be 
suspended  free  in  the  amniotic  sac.  According  to  Braiin,  when  the  am- 
niotic fluid  is  produced  tardily,  the  amnion  is  torn,  while  the  chorion  re- 
mains intact.  Under  the  influence  of  the  foetal  movements  the  amnion 
becomes  rolled  around  the  cord,  and  induces  thus,  by  compression,  the 
death  of  the  foetus.  (Fig. 23.)  Finally,  these  amniotic  folds  may  be  pro- 
duced after  the  death  of  the  foetus  by  diminution  of  the  liquor  amnii. 

According  to  Crede,  these  bands  are  necessarily  found  in  the  third  or 
fourth  weeks  of  foetal  development,  or  before  the  closure  of  the  ventral 
cavity;  for,  in  admitting  hiflammation,  it  is  only  possible  to  affect  those 
parts  still  projecting.  Ordinarily,  however,  it  is  in  the  deep  part,  or  in 
their  neighborhood,  that  the  amnion  is  adherent.     And,  moreover,  one 


Fig.  23.— Amniotic  Bands.    (After  ^raiiw.)     a,  Cutaneous-bridge.    6,  Liver,    c,  Osseous  stump 
of  left  lower  limb,    d,  Left  foot,    e,  Right  foot.    /,  Vulva,    gr,  Anus,    /i/i,  Amniotic  bands. 

never  sees  those  ulcerations,  capable  of  traversing  the  abdominal  integu- 
ment, and  even  of  the  bone,  in  cases  of  tuberculosis,  scrofula,  rachitis, 
syphilis,  etc.  It  is  later,  in  the  eighth  week,  that  these  lesions  are  pro- 
duced. In  the  second  month  the  foetus  is  separated  from  the  amnion  by 
a  notable  quantity  of  liquid,  and  the  amnion  adheres  to  the  chorion.  It 
is,  therefore,  before  this  that  they  are  produced,  that  is,  towards  the  time 
of  formation  of  the  amnion,  the  third  week.  Another  proof  is  the  differ- 
ence that  exists  between  the  amnion  and  the  skin  of  the  foetas.  From 
the  eighth  week  the  foetus  has  its  epidermic  covering,  and  this  cannot  fur- 
ther proliferate.  In  the  third,  on  the  contrary,  the  amnion  is  developed, 
and  tends  to  blend  towards  the  middle  of  the  back  of  the  foetus,  and  its 
folds,  before  they  unite,  form  an  acute  angle;  and  he  believes  that  the  ex- 
aggeration of  the  amniotic  fold  becomes  the  origin  of  the  premature 


DISEASES    OF   THE   OVUM.  283 

formation  of  cells  and  nuclei,  which,  manifesting'  themselves  on  each 
side,  induce  premature  fusion  of  the  two  amniotic  folds.  If,  on  the 
other  hand,  one  remembers  that  Keichert  and  Remak  consider  the  amnion 
as  composed  of  two  layers,  one  epidermic,  in  connection  with  the  skin  of 
the  embryo,  the  other  in  immediate  continuation  with  the  cutaneous  layer, 
one  understands  that  the  folds  are  able  by  their  traction  to  cause  the 
flexion  of  the  foetus  and  help  to  give  it  its  form.  Braiin  finds  the  cause 
of  this  adhesion  in  the  too  little  quantity  of  fluid,  or  the  too  tardy  sepa- 
ration of  the  amnion,  and  in  concussion  of  the  foetus,  which  forces  it  to 
lengthen,  instead  of  remaining  bent.  (Stadhagen.)  Crede  depending 
on  the  researches  of  Panum,  of  Dareste,  believes  in  the  influence  of  the 
variations  of  temperature  and  variations  of  pressure  in  the  uterine  con- 
tractions, and  the  sudden  vaso-motor  disorders,  produced  in  the  uterus 
by  the  emotions  and  physical  influences. 

What  is  the  relation  between  monstrosities  and  these  amniotic  bands? 

Crede,  out  of  109  cases  of .  monstrosities,  has  found  69  of  them  with 
amniotic  bands,  and  21  Avith  liernise  cerebri,  eventrations,  spontaneous 
amputations,  and  atrophies  of  the  bones.  The  opinion  of  Braiin,  who 
thinks  that  the  spontaneous  amputations  are  produced  more  frequently 
in  the  upper  than  the  lower  extremity,  because  the  upper  are  more 
prominent,  is  not  sustained  by  Credo's  cases.  On  the  other  hand,  amni- 
otic adhesions  are  more  common  in  the  upper  extremity.  Out  of  11 
cases,  ?  were  of  the  upper  extremity.  All  agree  that  the  spontaneous 
amputations  are  due  to  the  amniotic  bands. 


CHAPTER   TV. 

DISEASES   OF  THE   FCETUS. 

npHE  diseases  of  the  foetus  and  the  embryo  are  as  yet  little  known,  not- 

-*-   withstanding  the  progress  in  this  direction  made  during  recent  years. 

Of  those  appertaining  directly  to  teratology  we  say  a  few  words  only; 

others,  more   directly  interesting  to  the  obstetrician,  not  only  because 

they  compromise  the  life  of  the  foetus,  but  because  they  occasion  serious 

difficulties  at  labor,  we  refer  to  under  Dystocia. 

The  first,  the  true  foetal  diseases,  we  will  pass  in  review. 

ft 

Fevers. 

The  eruptive  fevers,  the  intermittent  fevers,  and  typhoid  fever,  have 
been  studied  with  reference  to  their  influence  on  pregnancy  and  the  foetus, 
in  detail.  (See  Diseases  of  Pregnant  Women.)  The  same  is  true  of 
icterus. 

Cerebral  Diseases. 

Scanzoni  distinguishes:  1.  Hypertrophy  of  the  brain,  which  sometimes 
occurs  to  such  a  degree  that  it  impedes  the  development  of  the  cranial 
vault,  sometimes  partially,  sometimes  totally.  In  the  first  case,  the  head, 
notwithstanding  its  exaggerated  volume,  is  soft  and  compressible,  the 
bones  are  thin  and  compressible,  and  their  compressibility  is  still  further 
increased  by  the  size  of  the  fontanelles  and  sutures.  In  the  second  case, 
the  hypertrophy  may  lead  to  hemicephalus. 

2.  Hemorrhages. — They  may  occur  in  the  brain,  but  ordinarily  they 
are  vascular  or  intra-meningeal  apoplexies.  In  two  cases,  the  cord  has 
been  found  around  the  neck;  once  with  a  true  twist  of  the  cord,  and 
twice  with  numerous  apoplectic  nuclei  in  the  placental  parenchyma.  Usu- 
ally the  cause  escaped  notice.  3.  Hydrocephalus,  with  atrophy,  more  or 
less  extensive,  of  the  brain.     We  will  study  it  in  detail  under  Dystocia. 

Diseases  of  the  Eespiratory  Organs. 

Depaul,  Jacquemier,  Dubois  and  Desormeaux,  have  noticed  true  croup- 
ous, and  even  purulent  pneumonia,  in  the  lungs  of  the  foetus  and  before 
the  air  had  penetrated  the  pulmonary  vesicles.  Scanzoni  and  Eokitansky 
have  never  found  them,  but  they  admit  them  more  willingly  since  the 
pleural  inflammations  have  been  observed  and  described  by  Jacquemier, 


DISEASES    OF    THE   FCETUS.  285 

Veron,  Tarnier;  and  their  existence  is  absolutely  incontestable.  The 
existence  of  tubercles  and  emphysema  in  the  lungs,  have  been  also  noted. 
(Depaul,  Hecker.)  A^'cron,  Depaul,  Dubois,  have  noted  alterations  of  the 
thymus,  which  have  been  demonstrated  to  be  syphilitic.     (See  syphilis.) 

Diseases  of  the  Digestive  Tract. 

Billiard,  Scanzoni,  Eokitansky,  Desormeaux  and  Drouadaine,  have 
noted  different  changes  in  the  alimentary  canal.  In  the  case  of  Billiard, 
there  was  injection  and  redness  of  the  pharynx,  larynx  and  oesophagus. 
The  stomach  presented  a  certain  number  of  little  ulcerations;  besides  a 
general  discoloration,  without  softening  of  the  mucous  membrane,  the 
intestine,  at  the  csecum,  presented  a  series  of  whitish  follicles  enclosed  in 
a  red  circle,  but  not  ulcerated.  Desormeaux  has  noted  a  case  of  enteritis 
very  distinct,  old  and  very  intense.  To  Scanzoni  and  Carteaux,  the  in- 
testinal mucous  -membrane  presented  every  degree  of  hypergeniia.  It 
occurred  rapidly  and  violently,  it  gave  place  to  bloody  extravasations 
wdth  an  accompanying  hemorrhagic  peritonitis.  If  it  were  less  intense  and 
progressed  more  slowly,  it  was  confined  to  the  more  or  less  pronounced 
inflammation  of  the  intestinal  follicles.  Eokitansky  has  seen,  in  some 
rare  cases,  these  inflammations  produce  false  membranes.  Cases  of  in- 
testinal perforation  are  still  more  rare.  (Scanzoni.)  The  entozoa  (asca- 
rides  lumbricoides  and  taenia)  have  been  noticed. 

Diseases  of  the  Liver  ak"d  of  the  Spleeist. 

In  the  liver,  hepatitis  with  persistent  softening,  fatty  degeneration, 
hypertrophy,  induration,  etc.,  have  been  noted.  The  lesions  are  now 
recognized  as  syphilitic.  Euptures  of  the  liver,  due  to  traumatism  sus- 
tained by  the  mother,  may  occur.  In  the  spleen  the  same  lesions,  also 
syphilitic,  may  be  present. 

FCETAL   PERITOlsriTIS. 

The  miost  common  lesion  is  peritonitis,  which  has  been  studied  particu- 
larly, by  Simpson  and  Lorain.  Out  of  106  still-born  infants,  Lorain  has 
found  it  10  times,  and  out  of  193  infants,  born  alive,  but  dying  in  a  few 
hours  or  a  few  days  after  birth,  peritonitis,  sometimes  simple,  sometimes 
complicated  with  meningitis,  multiple  abscesses,  or  erysipelas,  has  been 
found  40  times.  (Lorain.)  As  we  shall  see,  the  existence  of  peritonitis 
in  the  foetus  and  the  newborn  is  due  to  the  same  cause  which  causes  it 
in  the  mother  after  delivery,  namely,  puerperal  fever,  which  attacks  the 
foetus  first,  and  the  mother  afterwards. 

Simpson,  previous  to  Lorain,  had  collected  23  cases,  2  of  them  per- 
sonal, some  borrowed  from  Allan,  4  cases;  from  Billiard,  3  cases,  from 
Banks,  Fisher,  Fairbain,  Cruveilliier,  Scott,  Veron,  Brachet,  Chaussier, 
Duges  and  Carus,  each  one  case,  a  total  of  10.    Finally,  4  cases  of  chronic 


286  TEEATISE    ON    OBSTETEICS. 

peritonitis,  2  from  Billiard,  and  2  from  Andral  and  Morgagni.  Since 
then,  sucli  cases  have  multiplied,  and  there  is  no  obstetrician  at  the  head 
of  a  large  hospital  who  does  not  each  year  observe  a  great  many  of  these 
cases. 

Patliological  Anatomy. — The  nature  of  the  effused  fluid  varies  consid- 
erably. Sometimes  it  is  purulent,  mixed  with  more  or  less  plastic  lymph. 
Sometimes  the  lymph  exists  alone,  or  mixed  with  a  large  quantity  of  serum. 
Sometimes  there  are  non-adherent  flakes  and  membranous  deposits  of  va^ 
rious  sizes,  floating  or  adherent;  sometimes,  soft  and  pulpy,  forming 
more  or  less  solid  adhesions,  or  even  true  false-membrane,  gluing  together, 
in  one  unique  mass,  the  abdominal  organs.  Concomitant  lesions  are 
thickening  of  the  intestines,  softened  liver,  persistent  infiltration,  inflam- 
matory nuclei  in  the  lungs,  bloody  clots  in  the  abdominal  cavity,  pro- 
ceeding from  a  rent  in  the  liver,  enormous  development  of  the  spleen, 
peritoneal  adhesions,  mesenteric  glands  enormously  swollen,  little  hemor- 
rhagic effusions  in  the  different  organs.  Generally  the  whole  peritoneum 
is  affected;  at  other  times  only  partially.  The  peritoneum  may  be 
hypertrophied  and  indurated. 

Causes. — Simpson  cites,  successively,  hard  work  on  the  part  of  the 
mother,  fatigue,  cold,  dampness,  a  physical  lesion  during  gestation,  peri- 
tonitis in  the  mother  during  pregnancy,  syphilis — especially,  anomalies  of 
abdominal  viscera,  and  accidental  effusion  of  irritating  liquids,  on  the 
peritoneal  surface  itself — urine,  and  rents  of  the  liver.  Lorain  does  not 
believe  in  the  very  great  influence  of  syphilis.  He  thinks  the  peritonitis 
due  to  the  puerperal  fever  which  is  manifested  as  in  the  mother,  by  the 
peritonitis,  and  is  reproduced  after  birth. 

Symptoms.  —  The  symptoms  are  more  than  obscure,  the  mother 
generally  having  experienced  only  the  cessation  of  movements,  accompa- 
nied sometimes  by  false  pains,  followed  by  the  signs  of  the  death  of  the 
foetus. 

Duration. — Nothing  is  definitely  known. 

Periods  of  Foetal  Life  when  Peritonitis  occurs. — Velpeau,  without  speci- 
fying, said  that  he  had  seen  incontestable  pathological  alterations  in  the 
lungs,  liver,  peritoneum,  and  other  parts  of  the  body  from  three  months. 
According  to  Simpson,  it  may  develop  at  all  ages,  even  at  term,  the  in- 
fants being  born  alive,  succumbing  from  a  few  hours  to  one  or  two  days 
after  birth.  Finally,  Lorain  has  observed  in  the  new-born,  hydrocele 
of  the  tunica- vaginalis,  erysipelas,  phlegmon,  phlebitis  and  arteritis  of  the 
umbilical  vessels. 

'    Diseases  op  the  Ctkctjlatoey  OnaAisirs. 

Inflammations  of  the  endocardium,  described  by  Cruveilhier,  those  of 
the  pericardium  and  the  consecutive  lesion  of  the  heart,  valvular  lesions. 


DISEASES    OF    THE    FCETUS.  287 

dilatation,  pericardiac  adhesions,  are  either  spontaneous  and  isolated  or 
dependent  on  inflammation  of  other  organs.  In  the  foetus,  the  right 
heart  is  especially  affected. 

Diseases  of  the  Skik  and  Cellular  Tissue. 

Besides  the  eruptive  fevers,  Moreau  has  found  different  colorings  of 
the  skin  in  the  dead  infant;  Naegele,  Edis  and  Ollivier  d' Angers,  mace- 
ration and  changes  in  the  epidermis  of  a  living  child;  Dohrn,  inflam- 
mation of  the  skin;  Houel,  a  case  of  hypertrophy  with  icthyosis:  Char- 
pentier,  an  identical  case,  1877;  Simpson,  icthyosis;  W.  Smellie, 
icthyosis.  Finally,  pemphigus  has  been  noted,  which,  according  to 
Kceser,  1876,  is  always  syphilitic.  Still,  cases  of  non-syphilitic  pemphigus 
have  been  seen  by  Krauss,  Hervieux,  Hassan-Mahmoud,  Faloy  and  Des- 
ruelles.  One  of  the  most  interesting  is  that  of  Lorain  and  Prevost. 
There  existed  in  a  syphilitic  infant  pemphigus,  and  also  changes  in  the 
lungs.  Finally,  Ammon  has  cited  a  case  of  melanosis  of  the  eyes,  and 
Lobstein  a  case  of  cirrhosis.  Simpson  has  described  certain  tumors  of 
the  cervical  region,  and  spina  bifida.  Meckel  and  Otto,  a  cystic  tumor 
of  the  cellular  tissue,  situated  at  the  posterior  part  of  the  neck,  divided 
into  two  lateral  and  symmetrical  lobes,  by  the  ligamentum  nucha. 
Berndt,  Caesar  Hawkins,  Beatty,  MuUer  and  Henke,  cystic  congenital 
tumors  of  the  neck.  Simpson,  cystic  tumors,  whose  mass  consisted  of 
the  union  of  little  cells,  filled  with  a  thick  glairy  liquid,  at  the  upper  part 
of  the  neck,  and  projecting  more  or  less  into  the  mouth.  Wallmann  has 
described  a  similar  case.  These  are  true  ranulse,  consisting  of  hyper- 
trophied  salivary  glands.  Simpson,  tumors  in  the  cervical  region,  formed 
by  vascular  erectile  tissue,  deeply  situated  and  disappearing  on  pressure, 
—  on  the  contrary,  increased  by  crying  or  efforts.  One  of  these  was 
operated  on  later;  there  was  profuse  hemorrhage.  Under  the  name  of 
bronchocele,  has  been  described  congenital  hypertrophy  of  the  thyroid 
gland;  this  may  disappear  after  some  years;  Simpson  has  seen  5  cases  of 
it.  Ollivier  has  seen  in  front  and  to  the  right  of  the  neck,  a  tumor,  the 
size  of  a  hazel-nut,  of  a  whitish-yellow  color,  soft  and  fluctuating,  which 
yielded  pus.  Planteau,  in  1876,  collected  a  number  of  cases  of  cervical 
tumors.  Eiveau  Landreau  has  noted  a  case  of  purulent  ophthalmia, 
supervening  during  uterine  life. 

Taylor  records  abscesses  in  the  foetus;  Finnell,  intra-abdominal 
tumors;  Legendre,  hydrocele  of  the  cord;  Friedreich,  cancer.  The  intra- 
uterine foetal  pathology  is,  however,  as  yet  hardly  outlined. 

Scrofulous  Affections. 

Temporary  swellings  of  the  thyroid  gland  have  been  especially  noted 
in  face  presentations,  and  are  easily  explained,  but  there  exists  another 


288  A   TREATISE   ON    OBSTETEICS. 

raro  affectioij,  whicli  Spiegelberg  has  called '' struma  intra-uterina  con- 
genita." It  is  one  of  the  most  rare  diseases  of  the  foetus,  and  consists 
of  a  simple  parenchymatous  hyperplasia,  and  is  persistent.  It  comes  on 
endemically,  apart  from  the  general  hereditary  condition.  Congenital 
goitre  may  cause  brow  or  face  presentation,  in  causing  bending  of  the 
head.  Hecker,  Simpson,  Lohlein,  have  each  cited  a  case  of  it.  It  may, 
after  birth,  be  the  cause  of  respiratory  trouble,  and  even  of  death,  by 
compressing  the  \,rachea.  Both  Spiegelberg  and  Hecker,  the  first  in  two 
cases,  the  second  in  one  case,  have  observed  this  asthma  due  to  hyper- 
plasia of  the  thyroid. 

Afeectioks  of  the  Bones. 

Fractures. 

The  fractures  which  are  seen  in  the  foetus  may  be  produced  in  utero, 
or  may  result  from  traumatisms  occurring  during  delivery.  We  shall 
only  consider  the  first  variety.  Intra-uterine  fractures  are  due  to  a  de- 
fect of  ossification,  to  the  non-union  of  the  osseous  masses,  developed  from 
the  different  centres  (occurring  particularly  in  bones  of  the  head),  to  the 
separation  of  epiphyses,  this  separation  depending  on  an  inflammatory 
process,  or  a  non-union  of  the  diaphyses  with  the  epiphysis,  or  to  congeni- 
tal rachitis.  They  may  be  caused  by  some  traumatism  sustained  by  the 
mother,  which  may  leave  no  trace  on  her  body.  These  fractures  will  be, 
of  course,  more  readily  produced  where  there  exists  already  a  primary  de- 
fect of  ossification,  or  where  there  is  less  amniotic  fluid.  Almost  always 
the  extremities  are  the  parts  involved,  and  the  thigh  frequently,  since  its 
situation  exposes  it  unfavorably;  whereas  the  head,  from  its  form,  its 
situation  or  its  engagement  in  the  superior  strait,  usually  escapes.  The 
actual  displacement,  which  is  almost  always  seen  in  these  cases,  is  the 
result  of  muscular  traction,  which,  however,  has  not  prevented  union. 
Can  these  lesions  be  produced  in  the  uterus  in  healthy  bone,  without 
external  injury  ?  This  seems  at  least  doubtful  to  Spiegelberg,  who 
admits,  however,  that  in  these  cases,  there  may  have  been  a  protruding 
promontory  and  prolonged  compression  of  the  head  or  of  other  parts 
against  it.  Some  cases  of  fracture  of  the  cranial  bones  have  been  seen 
after  natural  labor  in  women  who  had  pelvic  deformity. 

The  prognosis  is  generally  not  grave.  These  fractures  heal  rapidly, 
unless  from  the  influence  of  complications,  gangrene  occur.  In  some 
cases,  however,  they  are  caused  by  lesions  of  which  traces  are  found  at 
birth,  in  the  form  of  pareses,  atrophy  of  limbs,  which  show  that  there 
have  been  lesions  of  the  nervous  trunks,  or  inflammation,  terminating 
by  atrophy  or  sclerosis. 

Cranial  fractures,  accompanied  by  hemorrhages,  by  concussion  or  by 
cerebral  contusions,  are  most  often  fatal.     If  these  last  injuries  are  es- 


DISEASES    OF    THE    FCETUS.  289 

caped,  tlie  infants  may  recover  from  the  fractures.  Concerning  the  tor- 
sions, the  forced  flexions,  the  general  compression  of  the  foetus,  they  may 
be  caused,  considering  the  little  space  the  foetus  occupies,  by  either  an 
internal  pressure  exercised  on  the  foetus  by  uterine  or  peri-uterine  tumors, 
by  deformity  of  the  pelvis,  by  insufficient  liquor  amnii.  Hohl  and  Con- 
rad have  collected  a  certain  number  of  examples. 

Luxations. 
Concerning  luxations,  the  etiology  is  obscure.  They  may  be  ascribed 
to  an  anomaly  of  development  of  the  articular  cavity,  which,  in  conse- 
quence of  causes  to-day  still  unknown,  manifested  itself  first,  not  at  the 
normal  point,  but  at  some  other  point  of  the  iliac  bone.  It  is  curious  that 
the  greatest  number  of  these  observations  have  been  in  female  foetuses. 
Fehling  believes  that  these  depend  on  the  fact  that  the  flattened  portion 
of  the  iliac  bones  was  extended.  In  this  connection  it  is  necessary  to 
cite  the  coxalgia  observed  by  Bird,  Broca,  Morel  Lavalle,  Padieu,  and 
the  curious  cases  of  ankylosis,  by  Bird,  Eichaud,  Joulin;  of  ankylosis 
with  hydrocephalus,  by  Becourt;  and  of  gibbosity  with  or  without  hy- 
drocephalus by  Joulin,  Mantoux,  Nivert. 

Spontaneous  Amputations. 

Under  the  name  of  intra-uterine  amputations,  spontaneous  amputations 
or  congenital  amputations,  are  designated  certain  defects  of  conforma- 
tion, characterized  by  total  or  partial  absence  of  one  or  more  extremities. 
Duplay,  holding  rightly  that  among  these  defects  some  are  due  to  failure 
of  the  normal  evolution  of  the  limbs,  an  arrest  of  their  development, 
others  due  to  the  action  of  some  mutilating  agent,  which  cuts  them  off 
as  with  the  surgeon's  knife,  designates  them  as  congenital  amputations. 
The  first,  considered  under  teratology,  group  of  edromeliens  (Geoffrey 
Saint-Hilaire),  we  shall  not  consider  here.  The  second  directly  con- 
cern the  obstetrician. 

Causes. — While  Haller  attributes  them  to  malformations  and  not  to 
separation  of  formed  parts,  Chaussier,  the  first  to  find  in  the  uterus  the 
separated  part,  attributes  them  to  gangrene,  but  Watkinson  shows  that, 
although  the  stump  was  largely  cicatrized,  the  foot,  found  in  the  uterus, 
showed  no  trace  of  putrefaction,  and  appeared  to  be  in  a  state  of  perfect 
preservation,  and  therefore  excluded  the  idea  of  gangrene.  Montgomery, 
Levert,  Simonart,  have  shown  that  these  amputations  result  from  constric- 
tions of  the  extremities,  sometimes  by  the  umbilical  cord,  most  often  by 
bands  of  false  membrane,  which,  looped  about  the  extremities,  completely 
cut  them  off;  the  bands  are  developed  in  the  interior  of  the  amniotic  cav- 
ity. Whether  these  bands  are  due,  as  Montgomery  thinks,  to  an  inflam- 
mation of  the  foetal  membranes,  accompanied  by  an  effusion  of  plastic 
lymph,  or  as  Simonart,  Moreau,  and  German  authors  think,  to  the  am- 
VOL.  II.— 19 


290  A    TREATISE    ON    OBSTETRICS. 

niotic  bands,  the  instances  have  mnltiplied,  and,  by  those  of  Zagorski  and 
of  Montgomery,  we  are  able  to  follow  the  lesion  from  its  beginning,  a 
simple  cutaneous  depression,  np  to  a  complete  amputation.  These  bands, 
indeed,  fixed  by  both  extremities  to  the  internal  surface  of  the  membranes, 
form  rings  or  loops  in  which  any  part  of  the  foetus  may  be  entangled. 
But  authors  are  not  all  agreed  as  to  the  action  of  these  bands.  Mont- 
gomery thinks  that  the  ligature,  in  compressing  the  vessels  more  and 
more,  obliterates  those  of  the  bones  themselves,  whose  vitality  ends  by  the 
obliteration;  and  these  bones,  now  soft  and  friable,  are  entirely  separated 
by  the  foetal  movements.  He  has  observed  that  the  skin  and  soft  parts 
are  not  divided  but  depressed  inwards  to  the  bone,  so  that  when  the  sec- 
tion is  complete,  the  skin  covering  the  surface  of  the  section,  the  stump 
appears  cicatrized.  Martin  Jena  does  not  believe  that  the  simple  liga- 
turing is  able  to  act  on  the  bone,  unless  it  is  in  a  cartilaginous  state. 
He  thinks  it  should  limit  its  action  to  the  soft  parts,  and  the  cause  of 
these  amputations,  therefore,  must  be  exterior.  This  opinion,  given 
already  by  Simpson,  is  not  absolutely  tenable.  It  is  perhaps  true  in  cer- 
tain cases,  that  of  Martin  proves  it,  but  besides  that  the  ligature  acts 
frequently  on  the  cartilaginous  parts,  these  ligatures  have  often  produced 
incomplete  sections  only  including  the  soft  parts;  and  the  morbid  influ- 
ences which  cause  these  bands,  and  in  particular,  the  inflammation,  pro- 
duce functional  difficulties  and  organic  malformations,  incompatible  with 
the  life  of  the  foetus,  which  succumbs  often  before  the  separation  is  com- 
plete. Finally,  the  instances  of  Hecker,  Fitsch  and  Watkinson  prove  that 
the  mother  has  not  received  any  accident. 

Contrary  to  the  opinion  of  Braiin,  who  thinks  that  the  spontaneous 
amputations  are  produced  generally  on  the  upper  extremities,  it  is  in  the 
lower  extremities  that  Crede  and  Duplay  have  most  often  found  them,  and 
generally  on  the  left  side.  The  direction  of  the  cord  to  this  side,  ex- 
plains to  a  certain  extent  this  predilection. 

Sometimes,  and  it  is  the  rule,  the  stump  is  cicatrized;  sometimes  there 
is  a  wound,  generally  little  extended,  at  the  centre  of  the  stump.  In 
this  case,  the  bone  or  the  bones  of  the  member  are  prominent  on  the 
surface  of  the  wound,  as  in  a  circular  amputation,  in  which  the  stump 
would  be  conical. 

In  the  cases  where  these  amputations  are  due  to  a  veritable  malforma- 
tion, the  extremity  of  the  stump  has  one  or  more  appendages.  (Figs.  24 
and  25).  Sometimes  fingers  more  or  less  complete  with  phalanges  and 
nails,  sometimes  simple  cutaneous  tubercles;  and  in  these  cases,  Debout 
has  noted  extreme  sensibility  of  the  deformed  members,  due  to  the  enor- 
mous development  of  the  nerve  trunks,  which  does  not  exist  in  cases  of 
congenital  amputations.  Simpson^  who  has  observed  five  or  six  of  these 
last  cases,  believes  in  a  tendency  in  the  human  species  to  a  reproduction 
of  a  missing  extremity,  and  having  seen  in  a  case  of  Withe,  the  thumb 


DISEASES    OF    THE    FCETUS. 


291 


amputated,  first  by  Withe  and  a  second  time  by  Bromfield.  grow  again, 
he  supposes  that,  where  the  amputation  is  produced  in  the  early  part  of 
foetal  life,  at  a  time  when  the  physiological  activity  is  similar  to  that  of 
an  order  less  elevated,  the  lost  portion  is  perhaps  at  least  liable  to  a  par- 
tial and  rudimentary  restoration.  It  is  only  in  exceptional  cases  that 
these  bands  become  a  cause  of  dystocia.  The  only  case  known  is  that  of 
Bleeck,  but  Fitsch  has  observed  one,  in  which  the  amputated  part  had 
been  expelled  fifteen  days  before  the  birth  of  the  child,  following  spon- 
taneous and  premature  rupture  of  the  membranes.  Most  frequently  the 
children  are  still-born.  Gay  and  Martin  have  each  observed  a  case  of 
spontanous  amputation  with  birth  of  living  children,  and  which  have 
survived.  On  the  contrary,  in  cases  where  the  amputations  were  simply 
an  arrest  of  development,  the  children  are  often  born  living.     We  have 


Figs.  24  and  25.— Congenital  Spontaneous  Amputation. 


seen  an  example  of  this:  the  lesion  was  double;  there  was  a  slender  stump 
of  the  left  leg,  with  complete  absence  of  the  foot,  and  a  rudimentary  right 
foot  attached  to  a  very  atrophied  leg;  the  child  is  now  two  years  old.  As 
in  the  cases  of  Bleeck  and  Guy,  the  child  presented  by  the  breech. 

Beauregard  has  noted  in  the  negroes  and  Hindoos,  an  affection  which 
he  calls  dactylolysis,  and  which,  always  produced  in  the  little  toe,  at  its 
base,  consists  in  a  circular  strangulation,  which  transforms  it  into  a  thin 
pedicle,  which  breaks  off  if  not  cut  off.  At  the  same  time,  the  little  toe, 
deviating  from  its  direction,  deformed,  triple  in  size,  is  converted  into  a 
compact  spheroidal  mass,  like  a  little  ovoid.  Beauregard,  who  has  com- 
pared this  to  spontaneous  amputations,  describes  three  varieties  of  ectro- 
dactylia:  first,  complete  arrest  of  development,  true  abortion;  second 
brachydactilia^  arrest  of  phalangeal  development;  third,  spontaneous  am- 
putation. We  are  dealing  here,  then,  with  a  defect  of  conformation  and 
not  spontaneous  amputation. 


292 


A   TREATISE    ON   OBSTETRICS. 


Intra-uteeine  Eaohitis. 

The  description  given  by  Depaul  is  so  complete,  that  we  can  do  no  bet- 
ter than  borrow  from  him. 

'^ Recent  State. — The  size  of  the  head  strikes  one  at  once,  and  contrasts 
sharply  with  the  slight  development  of  the  trunk  and  extremities;  but 
this  disposition  is  rather  relative  than  real,  and  the  cavities  and  organs 
which  it  contains  are  in  the  normal  state.  The  vertebral  column  does 
not  present  an  unusual  curve.  It  only  seems  that  the  cervical  region  is 
a  little  short;  the  head  appears  as  if  placed  on  the  upDer  part  of  the  tho- 


FiG.  26. — Intra-Uterine  Rachitis. 

rax.  The  chest  has  a  very  pronounced  conical  form,  at  the  top  narrow, 
at  the  bottom  very  wide.  The  lower  border  of  the  cartilages  and  the 
xyphoid  appendix  are  as  if  turned  outwards,  and  show  themselves  under 
the  skin.  The  thorax  is  flattened  from  before  backwards.  The  four  ex- 
tremities are  remarkable  for  their  little  length  and  their  volume.  The 
upper  are  held  in  a  nearly  vertical  situation.  In  contrast,  the  clavicles 
are  very  long.  The  lower  limbs  appear  made  up  of  two  kinds  of  enlarge- 
ments, separated  by  a  furrow,  which  is  found  above  the  knee.  The 
upper  one  is  considerably  enlarged,  and  presents  a  rounded  surface  which 
is  directed  forward  and  a  little  outward.  Movements  of  the  articulations 
are  easy,   and  palpation  proves  the  tissues    sufficiently  firm.     Beneath 


DISEASES  Of  the  fcetus.  293 

the  skin,  which  is  normal,  exists  a  bed  of  fatty  cellular  tissue  of  the  usual 
thickness.  The  muscles,  normal,  are  relaxed;  the  aponeuroses  are  per- 
fectly adapted  to  the  conformation  of  the  limbs,  and  do  not  hamper  them 
in  any  direction.     There  is  no  anomaly  in  the  nerves,  nor  in  the  vessels. 

^^ Lesions  of  tlie  Skeleton. — Cranium. — The  fontanelles  are  wide,  but  not 
of  the  usual  shape;  sometimes  normal,  as  also  the  sutures.  Ossification  of 
the  bone  is  regular  and  complete. 

"■Face. — In  proportion  to  the  cranium,  is  normal.  Maxillary  bones  well 
developed  and  regular,  containing  the  teeth-germs.  Eorehead,  normally 
prominent. 

'■^Thorax. — The  capacity  is  not  considerable,  very  wide  at  the  base,  when 
the  sides  and  the  cartilages  are  strongly  thrown  outwards.  The  ribs  are 
regularly  curved;  sufficiently  slender  at  their  vertebral  extremities,  they 
commence  to  increase  toward  the  anterior  part,  and  terminate  by  a  consid- 
erable enlargement.  This  is  not  marked  except  in  the  first  three  and  last 
two.  At  the  centre  of  each  of  these  extremities,  which  is  hollowed  out, 
starts  the  cartilage,  which  is  slender  and  filamentous.  Certain  of  the 
intercostal  spaces  are  wanting.  Besides,  the  ends  of  certain  ribs  are 
sharply  and  abnormally  curved  upwards. 

^' Upper  Extremities. — The  clavicles  are  very  long,  considering  the  di- 
mensions of  the  thorax.  Their  curves  are  not  exaggerated.  The  result 
is  that  the  scapula)  are  thrown  backwards,  and  tend  to  overlap  at  the 
spinal  border.  The  volume  is  not  abnormal  either  in  the  shafts  or  the 
extremities.  The  scapulas  are  but  little  altered  in  form,  and  present  a 
curve  backwards,  which  increases  the  depth  of  the  intra-spinous  fossae  to 
such  an  extent  that  it  effaces  the  subscapular  fossae,  which  are  replaced  by 
a  convexity.     The  ossification  is  normal. 

"Humerus. — Eepresents,  on  each,  side,  the  arc  of  a  circle,  strongly 
curved  on  its  anterior  plane;  the  convexity  is  backward,  on  its  posterior 
plane.  The  osseous  surface,  which  belongs  to  the  concavity,  is  flat  and 
almost  excavated;  that  of  the  projecting  part  is  rounded  in  its  whole  ex- 
tent. Besides  this  general  curve,  another  is  seen  toward  the  lower  third, 
the  concavity  directed  outwards,  the  convexity  inwards.  The  two  ends 
are  noticeably  enlarged.  The  upper  end  has  a  rounded  form,  the  lower 
is  more  extended  transversely  than  from  before  backward;  the  epiphyses, 
entirely  cartilaginous,  are  reduced  by  dessication  to  a  very  small  size. 

"Radius  and  Ulna. — Of  equal  length,  but  whereas  the  radius  exceeds 
the  ulna  below,  this  exceeds  the  other  above,  and  in  the  same  proportion. 
The  intra-osseous  space  is  narrow  and  elliptical,  the  extremities  are  of 
considerable  volume.  A  double  inflection  exists,  the  first  has  the  concav- 
ity anteriorly,  and  the  convexity  posteriorly;  the  second,  the  concavity 
internal  to  the  radius  and  external  to  the  ulna. 

"Hand. — No  point  of  ossification  in  the  bones  of  the  carpus;  those  of 


294  A    TREATISE    OlST    OBSTETRICS. 

the  metacarpus  and  phalanges  are  regular  as  to  form  and  direction.  The 
size  is  above  the  normal. 

"Pelvis. — Sufficiently  regular  at  first,  but  the  upper  rim  of  the  pubes  is 
slightly  elevated,  hence  there  is  considerable  obliquity  of  the  superior 
strait.  Considerable  increase  in  the  transverse  diameter,  compared  to 
the  antero-posterior;  pubes  and  ischio  pubic  rami  cartilaginous,  the  other 
parts  regularly  ossified. 

""Femora. — Curve  is  very  marked,  directed  backward  and  inward.  A 
second  curve,  with  internal  concavity  and  external  convexity  less  pro- 
nounced; extremities  largely  increased  in  size. 


Fig.  27.— Intea-Uterine  Rachitis, 

"Tihice. — Large  and  very  short,  very  obliquely  cut  away  at  the  upper 
part,  from  above  downward  and  behind  forward.  Curve  gentle,  concavity 
backward  and  outward,  convexity  forward  and  inward.  The  lower  ex- 
tremity presents  an  analogous  curve. 

"Fihulm. — Placed  more  posteriorly  than  normal;  slight  curve,  concavity 
anterior  and  internal;  convexity,  posterior  and  external;  separated  from 
the  tibise  by  a  large  elliptical  space.  Normally  large;  much  enlarged  at 
the  ends. 

"Feet. — Tarsus  completely  cartilaginous,  metatarsus  and  toes  abnormally 
ossified  and  formed;  feet  incline  outwards  in  relation  to  the  leg. 

"  Vertebral  Column. — Nothing  unusual,  spinous  and  transverse  processes 
cartilaginous,  with  ordinary  points  of  ossification. 

"Periosteum. — Thin,  regular,  normally  adherent." 


DISEASES    OF    THE    FCETUS.  295 

This  description^  wliicli  relates  to  a  foetus  of  seven  and  a  half  months, 
born  alive,  but  respiration  failed  to  be  established,  is  typical  and  charac- 
teristic. But  in  other  cases  different  alterations  are  observed.  In  a  case 
seen  by  Gucniot,  and  in  another  seen  by  myself  (and  whose  skeleton  is 
found  in  the  museum  of  the  Clinic),  the  changes  were  identical.  Besides 
the  curves  and  the  enlargements  of  the  epiphyses,  noted  by  Depaul,  we 
found  on  the  cranium  an  ossification  more  than  incomplete,  characterized 
by  some  disseminated  osseous  plates,  but  all  the  long  bones  and  the  lower 
jaw  presented  an  infinite  number  of  fractures  or  solutions  of  continuity. 
Each  bone  seemed  to  consist  of  little  osseous  masses,  mobile,  bound  to- 
gether by  the  periosteum,  which  rendered  the  dissection  very  difficult. 
But,  contrary  to  the  observations  of  Guc'niot,  in  our  case  all  the  bones 
of  the  skeleton,  vertebral  column,  pelvis,  hands  and  feet,  participated  in 
the  changes.  Spiegelberg  has  found  these  same  changes,  and  has  seen 
the  curves  of  the  bone,  the  enlargement  of  the  epiphyses,  and  the  frac- 
tures, with  remarkable  integrity  of  the  clavicle.  He  noted:  the  flatten- 
ing of  the  pelvis,  the  extension  of  the  sacrum,  the  deviation  of  the  prom- 
ontory forward  and  downward,  transverse  flattening  of  the  sacral  vertebrae- 
and  the  iliac  crests,  increase  of  the  pubic  arch,  the  characteristic  superior 
strait,  and  ossification,  sometimes  incomplete,  sometimes  almost  exag- 
gerated, of  the  cranium. 

Depaul  does  not  believe  that  these  cases  are  true  instances  of  intra- 
uterine rachitis,  and  holds  that  in  each  of  the  observations  there  has  been 
omitted  mention  of  the  sign  which  characterizes  the  second  period  of 
rachitis,  namely,  sofhwiing  of  the  bony  tissue;  but,  while  extra-uterine 
rachitis  rarely  invades  the  whole  skeleton,  and  has  a  predilection  for  the 
long  bones,  in  so-called  infra-uterine  rachitis  the  whole  of  the  skeleton 
is  invaded.  Only  the  points  of  ossification  which  are  in  the  spine  appear 
as  exceptions.  The  deformity  is  produced  with  a  certain  symmetry  on 
the  corresponding  bones.  Contrary  to  Spiegelberg's  opinion,  the  curves 
are  generally  in  relation  Avith  the  muscular  action,  sometimes  more  mani- 
fested inversely.     Finally,  there  is  no  arrest  of  development. 

In  all  probability,  the  affection  began  at  a  slightly  advanced  period  of 
foetal  life  where  as  yet,  only  a  little,  if  any,  calcareous  material  had  been 
deposited  in  the  tissue.  As  a  result,  it  is  necessary  to  reject  the  idea  of 
a  deformity  succeeding  a  perfectly  regular  state,  and  to  recognize  the  in- 
fluence of  a  single  cause,  namely,  an  unequal  distribution  of  the  material 
which  gives  to  the  bones  their  form  and  their  solidity.  In  short,  in  the 
true  rachitis,  the  entire  organism  appears  affected,  while  in  the  case  of 
intra-uterine  rachitis,  the  lesion  appears  exclusively  confined  to  the  bony 
system. 

Concerning  the  solutions  of  continuity  which  are  described  under  the 
name  of  fractures,  Depaul  believes  them  to  be  of  two  kinds:  the  one,  the 
true,  due  to  external  violence,  to  exagger?«ted  muscular  contractions,  or 


296  A    TREATISE    ON    OBSTETRICS. 

to  an  essential  weakening  of  the  tissue,  which  lies  at  the  seat  of  the 
trouble;  and  the  other,  the  false,  those  which  coincide  with  the  supposed 
intra-uterine  rachitis. 

Even  as  the  curvature  may  be  explained  by  an  unequal  development 
of  the  different  parts  of  the  same  bone,  so  may  the  solutions  of  continu- 
ity result  from  the  fact  that  calcareous  deposits  are  not  made  in  one  or 
more  points  of  the  shaft;  hence  it  is  not  a  fracture  which  occurs,  but  an 
absence  of  ossification.  It  is  of  no  account  that  there  has  been  noted  in 
many  observations,  in  that  of  Chaussier  in  particular,  the  existence  in 
the  course  of  some  of  the  long  bones  of  certain  enlargements,  which  have 
been  cited  as  proof  of  fractures  which  have  united,  for  there  is  nothing  to 
show  that  there  is  true  callus.  A  limited  prominence  of  bony  tissue  is  all 
that  exists,  and  it  is  not  harder  to  understand  this  superabundance  of 
the  calcareous  material  than  the  diminution,  the  absence  or  irregular- 
ity of  its  deposit;  and,  according  to  Depaul,  all  these  alterations  of  the 
bony  tissue  are  of  the  same  nature,  and  due  to  the  anomalies  of  ossifica- 
tion. The  health  of  the  mother  has  nothing  to  do  with  their  development. 
In  no  case  has  scrofula,  rachitis  or  syphilis  been  found.  In  many  in- 
stances, the  disease  has  occurred  in  twin  pregnancies,  which  fact  is  prob- 
ably connected  with  the  development  of  the  rickets. 

As  opposed  to  these  ideas  Spiegelberg  says  that  histological  examina- 
tion proved  that  the  process  is  identical  in  intra-uterine  and  extra-uterine 
rachitis. 

Winckler  makes  two  subdivisions:  rachitis  micromelica  and  annular 
rachitis.  The  first  is  eminently  intra-uterine;  til  second,  beginning, 
possibly,  in  the  last  months  of  pregnancy,  passes  into  the  intra-uterine 
phases  of  rickets.  Miiller  has  described  a  special  alteration  in  the  bones, 
characterized  by  disease  of  the  primitive  cartilages.  Of  all  the  diseases  of 
the  bones,  that  affecting  the  inner  surface  of  the  skull  is  the  rarest. 
Spiegelberg  once  found  a  gumma.  Wegner  detected  lesions  of  the  bony 
canaliculi.  In  general,  the  changes  in  the  bones  are  most  marked  in  the 
end  of  the  femur,  then  in  the  lower  extremity  of  the  tibia,  and  in  the 
radius  and  ulna;  later  in  the  upper  extremity  of  the  humerus  and  of  the 
radius,  and  lastly  in  the  lower  extremity  of  the  humerus.  This  alteration 
is  usually  due  to  syphilis  of  the  father.  In  addition  to  osteo-chondritis, 
Wegner  has  noticed  alterations  in  the  marrow  of  the  canaliculi,  sometimes 
diffuse,  and  sometimes  in  isolated  patches.  The  medullary  tissue  is  red- 
dish, and  under  the  microscope  is  found  to  be  in  a  state  of  fatty  degener- 
ation, especially  of  the  medullary  cells  and  the  walls  of  the  vessels. 

Congenital  Syphilis. 

In  studying  maternal  syphilis  we  have  shown  the  conditions  in  which 
the  disease  is  transmitted  to  the  foetus.  In  connection  with  diseases  of 
the  placenta,  membranes  and  cord,  we  have  noted  the  lesions  which  are 


DISEASES    OF    THE    FOETUS.  297 

regarded  as  characteristic  of  syphilis;  it  now  remains  to  study  them  in 
the  different  systems  and  organs  of  the  f cetus. 

In  recent  years  hereditary  syphilis  has  been  studied  authoritatively  by 
Parrot,  from  whom  the  following  description  is  borrowed: 

Two  different  groups  of  lesions  are  produced:  one,  peripheral  or  super- 
ficial, located  on  the  skin  or  mucous  membranes;  the  other,  profound, 
which  affects  the  different  viscera  and  the  bones. 

The  cutaneous  lesions  are  bullae,  maculae  or  papules,  as  shown  by  the 
following  table. 

f  1.  Bullae  (pemphigus). 
2.  Maculae. 

Syphihdes,  {   g    piaaues  i  ^'■"''• 

I     ■         M.      5  i  lenticular. 

(^  4.  Vesico-papulffi  (very  rare). 

Ulcerous  syphilides  are  only  the  ordinary  syphilides  which  have  become 
ulcerated  by  the  action  of  external  bodies  or  under  the  influence  of  a 
generally  bad  condition.  The  more  intense  the  diathesis,  the  sooner  the 
syphilides  appear.  The  first  manifested  is  the  bullous  syphilides  (the 
pemphigus).  It  is  a  precocious  manifestation  of  extreme  gravity,  which 
often  coincides  with  visceral  lesions,  and  which  frequently  and  rapidly 
reaches  a  fatal  termination.  On  the  contrary,  the  lenticular  syphilides  is 
manifested  later;  it  ordinarily  appears  isolated.  The  vesico-papular 
syphilides  are  extremely  rare,  are  the  expression  of  a  vanishing  diathesis, 
and  of  little  gravity,  and,  as  intermediate  to  these  different  cutaneous 
lesions,  we  find  the  macular  syphilides,  rarely  isolated  and  united  some- 
times to  the  bullous  syphilide,  sometimes  to  the  "  plaque  "  syphilide  (syphi- 
litic roseola  of  authors).  The  mucous  patch,  the  most  frequent,  is  char- 
acterized by  permanent,  tenacious,  indurated  elevations  in  patches. 
The  patches  are  circular,  red  at  the  centre,  violet  or  salmon-red  at  the 
periphery.  They  are  found  about  the  anus,  on  the  lower  limbs,  thighs, 
scrotum,  labia  majora.  (The  child  at  the  same  time  has  coryza).  They 
ulcerate  easily.  On  the  face  they  often  become  crusted;  finally  they 
occur  on  the  scalp.  The  eruption  is  produced  in  eight,  ten  or  twelve 
days,  and  increases.  They  last  a  long  time.  The  lenticular  syphilides 
occur  on  the  buttocks,  the  upper  and  back  part  of  the  thighs  and  the  leg, 
the  labia  majora  and  the  scrotum;  these  are  the  true  lenticular  patches. 
Then,  the  buccal  ulcerations  appear.  But  while  all  or  nearly  all  the  buccal 
ulcerations,  due  to  marasmus,  are  symmetrical  and  lying  on  the  median 
line  or  at  symmetrical  points,  the  syphilitic  ulcerations  are  never  found 
in  the  median  line,  and  it  is  impossible  to  give  them  a  particular  topogra- 
phy. They  have  an  irregular  contour  and  a  hemorrhagic  tendency;  they 
occur  particularly  on  the  tongue,  on  the  internal  surface  of  the  cheeks, 
on  the  alveolar  border  of  the  maxillae,  and  quite  frequently  on  the  velum 


298  A   TREATISE    ON   OBSTETRICS. 

palati.  They  are  found  also  in  the  mouth,  as  red,  prominent  patche-?, 
similar  to  ordinary  mucous  patches.  On  the  lips  are  found  fissures,,  the 
true  rhagades,  erosions  and  projecting  mucous  patches.  When  the  chil- 
dren die  of  syphilis,  we  find  profound  lesions  of  the  bones  and  viscera. 
All  the  organs  may  present  the  lesions;  indeed  they  have  been  found  in 
the  brain,  where  occurred  a  softening  of  a  bluish-red  color,  and  little 
purule7it  nuclei,  located  near  the  longitudinal  fissure  and  to  the  left  side 
of  the  cerebellum.  But  these  four  organs,  the  thymus,  the  lungs,  the 
liver  and  the  spleen  are  always  affected.  In  the  thymus,  Dubois  has  noted 
the  presence  of  pus  diffused  or  collected  in  foci  in  the  parenchyma,  with- 
out clmnging  the  color,  form  or  size  of  the  organ.  The  observations  of 
Braiin,  Spaeth,  Depaul,  Wild,  Virchow,  Weber  and  Hecker,  have  con- 
firmed those  of  Dubois;  but  Spiegelberg,  who  also  found  these  changes, 
thinks  that,in  a  good  many  cases, there  is  an  increase  in  the  size  of  the  gland. 
In  the  lungs,  Dfepaul,  in  1851,  stated:  sometimes  true  collections  of  pus, 
or  more  or  less  thickened  cavities  enclosing  a  liquid  of  the  same  nature, 
are  found.  "I  have  many  times,"  said  he,  "found  another  disposition  which 
should  be  considered  as  the  first  degree,  and  which  consists  in  a  grayish 
induration,  without  as  yet  recognizable  pus,  with  a  considerable  deposit 
of  fibro-plastic  tissue.  Sometimes  the  lesion  was  disseminated  and  limited 
to  circumscribed  points;  sometimes,  on  the  contrary,  it  was  general  and 
had  invaded  one  or  more  lobes.  But  always  the  pulmonary  tissue  was 
impermeable  to  the  air,  as  proved  by  mucous  insufflations.  It  is  not  rare 
to  find  these  different  degrees  in  the  same  organ. ^'  The  lesions  are  con- 
nected with  other  conditions  characteristic  of  syphilis. 

Lebert  contests  the  presence  of  pus.  The  tissue  has  a  particularly 
yellow  color,  it  is  resistant  and  elastic.  At  the  middle  of  the  mesh,  formed 
by  the  pulmonary  network  of  fibro-plastic  elements,  is  found  a  soft  sub- 
stance, pulpy,  diffused,  and  in  which  are  many  little  cells,  which  are 
neither  cancerous,  nor  tuberculous  elements,  but  resemble  in  every  way 
the  cells  of  syphilitic  gummata. 

Liver, — There  is  described,  sometimes  simple  hypertrophy,  sometimes 
general  or  partial  congestion.  Gubler  has  described  the  organic  lesion 
which  is  peculiar  to  the  liver.     This  lesion  may  be  general  or  partial. 

1st.  General. — When  the  alteration  is  of  high  degree,  the  gland  shows 
a  yellow  color,  very  different  from  the  normal  condition,  and  which  is 
best  compared  to  the  hue  of  flint.  The  appearance  of  the  two  substances 
has  completely  vanished,  only  on  the  yellow  base  we  find,  on  close  atten- 
tion, a  more  or  less  clear  space  of  little  white  opaque  grains,  looking  like 
grains  of  millet,  and  free- arborizations  appertaining  to  the  exsanguin- 
ated vessels.  The  liver  is  sensibly  hypertrophied,  globular,  tinged,  hard 
«.nd  difficult  to  grasp  with  the  fingers;  it  tears  without  allowing  an  im- 
pression on  the  surface.  Its  elasticity  is  such  that  if  pressed  forcibly  be- 
tween the  fingers,  so  as  to  crush  a  wedge-shaped  piece  from  its  sharp  edge, 


DISEASES    OF    THE    FCETUS,  299 

the  piece  escapes  like  a  clierry-stone  from  tlie  compressing  fingers.  In- 
cised it  creaks  under  the  scalpel.  The  incisions  which  are  made  into  the 
liver  should  he  very  clean,  homogeneous,  and  the  great  consistence  allows 
us  to  obtain  very  thin  sections,  semi-transparent,  which  to  a  certain  de- 
gree are  found  in  the  naturally  thinned  portions  of  the  organ  (as  the  bor- 
ders and  especially  in  the  tongue  which  terminates  the  left  lobe. ) 

2d.  Partial. — This  form  is  more  common  than  the  general.  The  liver 
is  less  enlarged  and  shows  an  undecided  coloring,  shaded  yellow  and  red- 
dish-brown. No  part  of  the  parenchyma  appears  entirely  sound.  At  the 
same  time  the  liver  has  a  certain  semi-transparency,  which  allows  one  to 
distinguish,  at  a  little  depth,  millet-like,  the  grains  with  which  its  sub- 
stance appears  strewn.  These  opaque  points  are  here  more  numerous  and 
compact.  In  fact  these  opaque  grains,  plunged  lightly  into  the  transpar- 
ent substance,  reproduce  to  a  certain  point  the  aspect  of  the  two  sub- 
stances which  constitute  the  hepatic  tissue,  but,  beyond  that,  the  grains 
are  separated  by  very  great  intervals,  the  surface  substance  does  not  re- 
semble particularly  the  net-work,  essentially  vascular,  of  the  areolar  spaces 
■of  the  healthy  state. 

Under  the  microscope  we  find,  in  the  altered  tissue,  a  considerable, 
sometimes  enormous,  quantity  of  fibro-plastic  elements  in  all  stages  of 
evolution,  in  the  centre  of  which  the  ecchymosed  cells  are  dispersed.  The 
relation  of  these  fibro-plastic  elements,  by  their  connection  with  the 
proper  tissue  of  the  organ,  is  more  or  less  strong  as  the  alteration  is  more 
or  less  advanced.  There  is  very  little  in  the  parts,  still  brownish,  of  the 
second  form,  or  it  is  lost  in  the  midst  of  the  proper  cells.  They  are,  on 
the  contrary,  very  predominant  in  the  yellow  and  very  hard  livers,  as 
well  as  in  the  strongly  indurated  portions  of  the  livers  which  only  present 
a  partial  alteration,  while  they  exist  very  slightly  in  parts  whose  aspect  is 
■only  slightly  modified,  and  not  at  all  in  normally  appearing  tissue.  The 
fusiform  bodies  strike  us  at  first;  of  which  some  are  short,  shaped  like  a 
spindle,  the  others  very  long,  enlarged  in  the  centre,  and  terminating  by 
tapering  extremities.  Nearly  all  have  an  oval  or  ellipsoid  nucleus  enclos- 
ing a  granular  substance,  in  the  midst  of  which  are  noticed  one,  two,  or 
three  larger  granules,  of  a  more  fiery  brilliancy.  There  are  also  many 
rounded  or  oval  cells,  sufficiently  like  the  smaller  cells  of  the  parenchyma, 
but  enclosing  nuclei,  like  the  fibres.  In  some  cases,  especially  in  the 
general  form,  there  is  found  in  the  tissuejndurated  nuclei,  of  which  some 
are  soft  and  filled  with  a  purulent  material,  true  suppurating  gummata. 
Under  pressure  the  liver  yields  a  yellowish  liquid,  a  little  ropy,  partly 
coagulable  by  heat.  The  heart  is  soft  and  flabby,  containing  a  currant- 
jelly  like  liquid,  characterized  by  a  notable  diminution  of  the  globules, 
which  are  dissolved  in  albumin.  The  pericardium  and  the  cardiac  mus- 
cular tissue  are  filled  with  milky  patches. 

Peritoneum. — We  have  noted  the  hemorrhagic  peritonitis  of  Simpson. 


300  A    TEEATISE   ON    OBSTETRICS. 

The  spleen  is  hypertrophied,  softened,  indented,  permeated  witli  indu- 
rated nuclei,  as  the  disorganization  is  more  or  less  advanced. 

The  pancreas  presents  analogous  alterations  to  those  of  the  liver.  Pro- 
liferation of  the  fibro-plastic  tissue,  induration,  hypertrophy;  on  section 
it  is  whitish,  brilliant.  The  structure  of  the  acini  has  disappeared  to  the 
naked  eye.  The  proliferation  is  extended,  not  only  to  the  intermediate 
tissue  of  the  glandular  groups,  but  also  to  the  intermediate  tissue  of  the 
acini;  it  compresses  them,  destroys  their  epithelium,  thickens  the  walls 
of  the  vessels  and  destroys  the  capillaries. 

The  kidney*  are  hypertrophied,  the  Malpighian  pyramids  contain  little 
yellow  nuclei,  indurated,  with  commencing  suppuration. 

On  the  intestines  one  finds  blackish,  indurated  patches  occupying  the 
entire  wall  of  the  intestine,  and  constituted  by  net-work  of  fibres,  holding 
entangled  at  their  centre  fatty  and  purulent  globules,  and  their  cells  hav- 
ing prismatic  angles,  rounded,  strongly  tinged  with  brown. 

Finally  we  find  the  osseous  lesions  which,  noted  vaguely  by  Waldeyer, 
Wagner,  Korner,  Taylor,  have  been  studied  in  detail  by  Parrot  and  Euge. 
Parrot  finds  that  in  every  foetus  bearing  on  the  skin,  the  mucous  mem- 
brane or  in  the  viscera,  the  marks  of  hereditary  syphilis,  the  bony  sys- 
tem is  altered.  These  lesions  may  exist  alone.  Parrot  has  observed 
them  in  a  very  clear  case.  The  long  bones  of  the  extremities,  excepting 
those  of  the  hands  and  feet,  are  with  the  scapulse,  the  iliac  and  cranial 
bones,  most  frequently  attacked;  then  the  ribs,  the  clavicles,  the  metacar- 
pal and  metatarsal  bones,  and  lastly  the  vertebrse.  But  these  last  are 
only  affected  when  the  disease  is  of  long  standing.  The  symmetry  of  the 
lesions  is  constant. 

Parrot  thinks  that  there  are  four  varieties,  or  better,  four  degrees  of 
the  lesion. 

"1.  Seen  in  foetuses,  and  in  infants  dead  a  few  days  after  delivery. 
The  bones  are  heavier  than,  normal.  Under  the  periosteum,  are  found 
osteophytes.  Around  the  diaphysis  the  same  osteophytes  are  found,  per- 
pendicular to  the  diaphysal  axis.  The  medullary  substance  is  very  much 
diminished,  and  the  medullary  canal  almost  obliterated.  The  scapula  and 
the  iliac  bone  are  also  covered  with  osteophytes. 

"  2.  The  bones  are  less  heavy,  the  new-formation  layers  less  dense,  and 
more  porous.  The  changes  affect  in  particular  the  inferior  part  of  the 
diaphysis  of  the  humerus,  the  upper  part  of  the  ulna,  the  anterior  surface 
of  the  femur,  and  the  internal  of  the  tibia.  A  peculiar  characteristic  of 
this  degree  is  the  gelatinous  atrophy  of  the  bones.  The  spongy  tissue  is, 
in  particular,  affected.  To  this  atrophy,  is  added  the  pseudo-syphilitic 
paralysis  of  the  new-born.  Fracture  occurs  at  the  cartilage.  Pus  forms; 
osseous  fragments  become  detached;  abscesses  occur,  which  may  spread 
to  the  joints  and  break  outwardly. 

"  3.   This  is  characterized  by  medullarization,  which  appears  in  cases  of 


DISEASES    OF   THE   FOETUS.  301 

longer  duration.  The  osteoplij^tes  are  still  present,  often,  as  also,  the 
gelatinous  atrophy.  But  the  changes  are  most  apparent  in  the  medullary 
substance,  which  spreads,  invading  gradually,  in  particular,  the  inferior 
region  of  the  humerus  near  the  nutrient  foramen.  It  is  here,  indeed, 
that  we  find  the  distinctive  mark  of  the  disease.  There  occurs  enlarge- 
ment of  this  extremity,  especially  from  before  backwards.  A  section  pCT- 
pendicularly  through  the  diaphysis,  reveals  the  lesion  best.  The  diaphy- 
sis  is  enlarged,  the  antero-posterior  diameter  may  be  doubled.  This  is  due 
to  one  or  two  layers  of  osteophytes.  The  chondro -calcareous  layer  is  not 
so  hard  as  in  the  normal. 

''4.  This  degree  is  characterized  by  the  formation  of  a  spongy  tissue  at 
the  periphery  and  end  of  the  diaphysis,  where  it  tends  to  replace  the 
chondro- calcareous  layer.  The  characteristic  deformity  of  the  humerus 
diagnosticates  the  lesion.  This  degree  is  faund  in  children  beyond  six 
months.  The  older  the  infant,  the  more  it  approaches  rickets  in  appear- 
ance. 

''Syphilitic  bones  of  the  first  degree, with  their  compact  osteophytes,  and 
their  gelatiniform  atrophy,  are  the  very  reverse  of  rachitic  bones.  The 
two  other  degrees  resemble  one  another,  but  the  characteristic  shape  of 
certain  bones,  in  particular  the  humerus,  and  the  greater  density  of  the 
spongy  tissue,  and,  further,  the  less  development  of  the  cartilaginous 
layer,  are  certain  signs  of  syphilis."     (Parrot.) 

Death  of  the  Fcetus. 

The  causes  of  foetal  death  are  numerous.  It  may  depend  on  the  father, 
through  alteration  in  the  semen ;  on  the  mother,  through  general  disease, 
irritability  or  excitability  of  the  uterus,  lesions  of  this  organ,  etc. ;  on  the 
fcetus  itself,  from  faulty  development  or  monstrosities;  on  the  annexes 
of  the  foetus,  membranes,  placenta,  cord.  Finally,  on  external  influ- 
ences, such  as  traumatism. 

Many  of  these  causes  we  have  already  studied  at  sufl&cient  length.  We 
will  refer  here  only  to  certain  facts  which  result  from  modern  physio- 
logical researches. 

Influence  of  liiijh  Materiial  Temperature  on  the  Vitality  of  the  Fcstus. 

Without  referring  here  to  the  transmission  of  disease,  variola,  intermit- 
tent fever,  etc.,  to  the  fcetus  from  the  mother,  the  researches  of  Hecker, 
Fielder,  Buhl  and  Winckel,  prove  that  acceleration  of  the  maternal  pulse 
from  disease,  may  cause  foetal  death.  The  foetus  sympathizes  with  the 
mother,  both  in  evening  exacerbations  and  in  morning  remissions  of  the 
pulse. 

Further,  Hohl,  in  1830,  Kaminsky,  in  1866,  Winckel,  in  1869,  and  es- 
pecially, Eunge,  in  1877,  have  proved  the  noxious  influence  of  elevation 
of  the  maternal  temperature  on  the  foetus. 


302  A    TREATISE    ON    OBSTETRICS. 

Runge,  whose  experiments  were  elaborate,  concludes:  1,  The  tempera- 
ture is  always  a  few  tenths  higher  than  that  of  the  mother.  2.  The  foetus 
is  killed  by  the  elevation  of  the  temperature  alone,  even  before  the 
mother  dies.  3.  A  maternal  temperature  of  107°,  even  though  it  lasts 
but  a  few  minutes,  will  inevitably  kill  the  fcetus. 

ACTION^    OF    THE    MaTEEISTAL   BlOOD    ON   THE   VITALITY    OF   THE   FcETirS. 

We  have  seen,  in  the  article  on  the  respiration  of  the  foetus,  that  there 
is  an  exchange  of  materials  between  the  foetus  and  the  mother  through 
the  placental  villosities.  As  Zweifel,  Gusserow,  Eunge  and  Porak,  have 
shown,  certain  soluble  salts  (salicylic  acid,  iodide  of  potassium,  benzoic 
acid),  certain  poisonous  substances  (chloroform,  ether,  alcohol)  may  pass 
directly  and  naturally  from  the  mother  to  the  child;  certain  forms  of 
virus,  certain  miasms  (variola,  syphilis,  malaria),  may  be  transmitted  by 
the  same,  from  the  mother  to  the  foetus,  finally,  the  gaseous  inter- 
changes are  particularly  apt  to  be  produced,  the  foetal  blood-glo- 
bule taking  oxygen  from  the  maternal  blood-globule.  But,  on  the  other 
hand,  it  appears  from  the  experiments  of  Zweifel,  of  Zunz  and  of  Andreas 
Hogyes,  that  when  the  maternal  blood,  from  any  cause,  cannot  renew  its 
oxygen  from  the  external  air,  if  the  maternal  blood  corpuscle  is  intact, 
and  preserves  its  absorbing  power,  it  in  its  turn  borrows  oxygen  from  the 
richer  foetal  blood  and  thus  endangers  the  life  of  the  foetus.  If  the  ma- 
ternal blood  corpuscle  is  altered,  or  if  it  has  lost  its  absorbing  power,  it 
does  not  take  up  the  foetal  oxygen,  and  the  foetus,  consuming  little,  con- 
tinues to  live  more  or  less  time  after  the  death  of  the  mother.  It  appears 
then  that  whatever  interferes  with  the  exchange  of  gases  and  nutritive 
materials  between  the  foetus  and  the  mother,  is  fatal  to  the  former. 

Then  the  utero-placental  circulation  may  be  obstructed  either  in  the 
uterine  vessels,  in  the  placental  villosities  or  in  the  cord.  It  is  thus  that 
uterine  tumors,  peri-uterine  tumors,  diseases  of  the  placenta,  bloody  effu- 
sions, changes  in  the  villosities,  degenera.tions,  may  act,  as  also  maternal 
diseases,  pyretic  or  apyretic,  gravido-cardiac  accidents;  certain  toxic  sub- 
stances, phosphorus,  lead,  arsenic;  violent  deaths,  asphyxia,  syncope, 
finally  all  the  causes  which  determine  the  premature  contractions  of  the 
uterus  or  obstruct  its  development;  also  lesions  of  the  cord. 

But  in  a  certain  number  of  cases  the  foetus  succumbs  without  any  cause 
being  found,  and  this  at  several  consecutive  |)i*egnancies  (13  times  in  a 
case  known  personally  to  us;  it  was  only  in  the  18th  pregnancy  that  she 
had  a  living  infant,  and  indeed  it  was  born  at  8  months).  In  these  cases, 
the  young,  strong  and  healthy  women  were  married  to  strong  and  vigor- 
ous men.  Nevertheless,  most  frequently  the  cause  of  death  of  the  fcetus 
may  be  found,  but  authors  are  not  agreed  on  this  point. 

Euge,  in  an  interesting  article,  "  uber  den  foetus  sanguinolentus,''  states 
that  most  authorities  believe  syphilis  to  be  the  usual  cause  of  foetal  death, 


DISEASES    OF    THE    F(ETUS.  303 

while  KSimpson  believes  that  it  is  only  a  secondary  cause,  the  primary 
being  the  existing  peritonitis. 

According  to  liuge,  the  foetus  sanguinolentus,  or  the  macerated  foetus, 
is  almost  always  the  outcome  of  syphilis. 

Leopold  believes  that  the  habitual  death  of  the  foetus  is  due:  1.  To 
syphilis;  2.  To  anemia;  3.  Chronic  diseases  of  the  mother;  4.  Heredi- 
tary tendencies.  [In  1883,  in  an  article  on  "Habitual  Miscarriage^'  we 
tabiilated  the  causes  of  foetal  death,  as  follows:  1.  Syphilis;  2.  Maternal 
anemia;  3.  Uterine  disease,  and  disease  of  the  uterine  appendages;  4. 
Uterine  displacements;  5.  Chronic  cellulitis  and  peritonitis;  6.  Laceration 
of  the  cervix;  7.  Intermittent  fever;  8.  Chorea;  9.  Bright's  disease;  10. 
Tumors  of  the  uterus,  and  in  its  neighborhood;  11.  Poisoning  from  me- 
tallic substances,  lead,  arsenic,  etc.,  seen  particularly  in  workers  in  the 
arts  where  these  metals  are  used;  12.  Eeflex  conditions.  These  latter, 
we  stated,  may  have  their  outcome  either  from  the  nervous  system,  in 
general,  or  from  the  uterus  and  its  appendages,  in  particular.  There 
are  some  women  so  delicately  nurtured,  so  highly  impressionable,  as  to 
react  to  the  slightest  nerve  stimulus.  Like  hot-house  plants  they  must 
be  watched  and  tended,  lest  the  slightest  influence,  outside  of  their  accus- 
tomed liahitcd,  afcect  them  unfavorably.  Gestation  with  them  is  often 
toxic.  The  uterus  repels  the  impregnated  ovum  as  it  would  a  foreign 
body. 

Of  the  above  causes,  it  is  apparent  that  certain  ones  are  more  likely  to 
act  than  others  in  causing  foetal  death.  In  any  given  case  of  repeated 
miscarriage,  the  greatest  care  is  necessary  to  determine  the  possible  cause. 

In  certain  cases  it  may  be  advisable  to  absolutely  forbid  sexual  inter- 
course during  gestation,  the  foetal  death  being  apparently  the  result  of 
the  congestion  which  accompanies  copulation. 

As  a  still  further  cause,  and  likely  enough  not  a  very  infrequent  one, 
we  would'  mention  the  uterus  septus.  This  is  all  the  more  likely  to  be 
overlooked,  because  of  the  difficulty  in  determining  the  malformation, 
except  on  very  careful  examination.  The  cause  of  death,  in  this  case,  is 
the  development  of  the  foetus  in  a  space  too  contracted  to  allow  of  its  due 
expansion.  Munde  recently  reported  a  case  of  this  nature,  before  the 
New  York  Obstetrical  Society. — Ed.] 

If  the  majority  of  the  causes  of  foetal  death  are  absolutely  beyond  the 
accoucheur's  control,  it  is  not  so  in  a  certain  number  of  other  cases,  and 
particularly  for  syphilis,  all  authors,  excepting  Despres  perhaps,  arguing 
that  a  careful  treatment,  begun  during  the  pregnancy,  can,  and  only  can, 
save  the  child.  Hence  the  precept  of  Depaul,  to  always  follow  an  anti- 
S3q3hilitic  treatment  in  women  who  abort  repeatedly,  without  known  cause, 
even  when  they  do  not  present,  nor  does  the  father,  traces  of  syphilis. 
A  large  number  of  cases  have  justified  this  treatment.  We  have  our- 
selves  plainly  observed  a  case;    four  abortions  without   known  cause. 


304  A    TREATISE    ON    OBSTETRICS. 

sypliilis  absent  in  the  father  and  mother,  at  least  in  appearance,  and  ab- 
solutely denied  by  both.  Anti-syphilitic  treatment  of  both.  Since,  two 
healthy  infants,  the  elder  is  two  years  old,  the  younger  just  9  months; 
neither  has  ever  presented  any  symptoms.  The  mother  has  been  able  to 
nourish  both. 

But,  when  the  an ti- syphilitic  treatment  fails,  have  we  the  right  to 
resort  to  premature  delivery?  To  us,  it  does  not  appear  even  doubtful; 
and,  without  hesitation,  we  should  induce  labor  in  the  weeks  which  pre- 
cede the  usual  death  of  the  foetus,  not  forgetting,  however,  that,  in  a 
good  many  cases,  the  death  seems  to  come  on  more  and  more  tardily, 
according  as  the  pregnancy  is  renewed.  Such  women,  who  have  begun 
by  abortion,  have  come  gradually  to  premature  delivery,  and  we  believe 
that  it  is  in  these  cases  especially  that  there  is  the  chance  of  success, 

[In  case  of  habitual  miscarriage  not  dependent  on  any  special  appre- 
ciable cause,  absolute  rest  in  bed  for  weeks  before  the  usual  period  of 
miscarriage,  and  for  some  weeks  afterwards,  associated  with  the  constant 
administration  of  the  chlorate  of  potass,  and  the  tincture  of  the  chloride 
of  iron,  will  sometimes  succeed  in  enabling  the  woman  to  go  to  term,  and  to 
give  birth  to  a  living  infant.  Cases  of  the  kind  have  been  recorded  by 
Barker,  Munde,  etc.,  and  we  are  familiar  with  two  instances. — Ed.] 

DUKATIOSr  OF  Ebtention". 

The  dead  foetus  may  remain  a  variable  time  in  the  uterine  cavity  before 
being  expelled.  There  is  no  absolute  limit.  Where  death  occurs  in  the 
course  of  an  acute  disease,  or  as  the  result  of  traumatic  influence,  expul- 
sion is  ordinarily  rapid. 

If,  on  the  contrary,  it  follow  a  chronic  affection,  syphilis  for  example, 
or  causes  which  only  act  slowly  on  the  foetus,  it  may  be  retained  longer 
in  the  uterine  cavity,  and  this  without  danger  to  the  mother.  Sheltered 
from  contact  from  the  air,  it  does  not  undergo  putrefaction,  but  a  pecu- 
liar alteration,  which  constitutes  maceration,  to  which  we  shall  return, 
and  the  health  of  the  mother  is,  in  general,  but  little  influenced.  At 
the  best,  some  trifling  pains  in  the  abdomen;  sometimes,  slight  general 
malaise,  without  fever,  and  slight  hemorrhage,  at  first  sero-sanguinolent, 
of  negative  odor  and  more  or  less  acid;  and  then  delivery  occurs  a  little 
more  slowly,  often  in  the  normal  way. 

However,  generally  the  foetus  is  expelled  rapidly  enough  after  death, 
but  may  be  retained  many  months  in  the  uterus. 

Such  are  the  cases  of: — 

Young,         .         .         .         .         .         .2  months  and  ten  days. 

Pridie,         .•         •         •         •         •  j-  3  months. 

jN  ewmann  &  Harley, 


^&"'  ;    :    :    :    [«»<>"*'- 


DISEASES    OF    THE    FCETUS. 


305 


3  months. 


Jacobi,         .         .         .         .         .         .5-2-  months. 

Peaslee,        .         .         .         .         .         .7  months. 

Cedcrsjold,  ......    8  months. 

Fairbank  (entire  ovum),       .         .         .3  months. 

Noggcrutli,  Chamberlain  and 

Peaslee  (fu'tus  only),    . 

Scbacher  (foetus  unchanged  at  the  end  of)  5  months. 

Stephen,       .  .....    4  months. 

AVarner  (ovum  entire,  unchanged),      .    6  months. 
MacClintock,       .         .         .         .         .4^  months. 

Hoist  (foetus  unchanged),    .         .         .5  months. 

In  addition  to  these  extraordinary  cases,  we  must  mention  what  have 
been  called  prolonged  gestations,  where  the  foetus  has  remained  in  the 
uterine  cavity  beyond  the  normal  term  of  gestation,  and  then  been  ex- 
pelled more  or  less  altered. 

Such  are: 


Manget, 

foetus  of  5  months 

retained  12  months 

Johns, 

'• 

a 

G 

'• 

i( 

5  to  6  months. 

Olshausen,     . 

i . 

3 

'■* 

'• 

H 

Madge, 

i  t 

a 

4 

a 

a 

11 

McMahon, 

cc 

a 

4 

a 

a 

18 

Voigtel, 
Uhlrich, 

9    years. 
2       " 

MacClintock, 

1       " 

Simpson, 
Keiller, 

pregnancy 

of  12    months. 

Hal  ley  &  Davis, 

I.  i 

'  •'    6    years. 

Menzies, 

ii 

"17    months. 

Prael, 
Hecker, 

ii 

i  i 

•'32    years. 
''•  14*     " 

Muhlbeck,    . 

ii 

'•  14|     " 

(See  in  this  connection,  "'Prolonged  Pregnancies.") 

At  what  period  do  the  infants  habitually  succumb,  and  how  long  before 
delivery?  These  are  the  two  questions  which  Euge  has  endeavored  to 
solve  in  his  memoir  on  infants  born  dead  and  macerated;  and,  basing  his 
assertions  on  the  comparative  vv^eights  of  the  foetuses,  and  on  the  mater- 
nal recollections,  he  has  arrived  at  the  following  conclusions,  which,  he  is 
careful  to  say,  are  only  approximate,  and  which  we  tabulate: 


Sypliilitic  CliUdren  .-67. 


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306  A   TREATISE    OlS    OBSTETRICS. 

.•  12. 

from  26th  to  31st  week  2. 

a       ii.       i<  e(  -I 

"       ..       ••  '^  5] 

a        a        a  a  n 

"     '••     "       "  2*. 

It  results,  then,  that  dead  and  macerated  children  are  usually  met  with 
from  6|-  months  to  10-J  months,  remembering  that  the  Germans  count 
pregnancy  by  lunar  months. 

But,  how  long  can  the  foetus  remain  in  the  uterine  cavity  ?  In  case  of 
abortion,  it  is  not  rare  to  see  the  foetus  expelled  and  the  placenta  retained 
to  vegetate  for  a  longer  or  shorter  time.  We  have  seen  three  cases  our- 
selves: once,  with  symptoms  of  putrid  infection  of  the  mother  (138  days), 
the  mother  recovered;  once,  three  months,  the  mother  having  no  other 
symptoms  than  little  trifling  floodings  from  time  to  time;  the  placenta 
was  expelled  during  our  absence,  and  the  associate  who  assisted  could 
not  give  us  any  information,  except  that  it  was  without  odor  and  shriv- 
elled up.  There  was  a  slight  hemorrhage.  In  a  third,  in  the  service  of 
Dr.  Guyot,  the  placenta  was  only  expelled  at  the  end  of  five  months. 

In  case  of  stillborn  and  macerated  foetuses,  it  is  generally  14  or  16 
days  after  the  cessation  of  the  foetal  movements  that  expulsion  should  take 
place,  according  to  Euge.  We  have  seen  two  cases,  in  which  one  followed 
this  rule,  14  days;  the  other  was  prolonged  until  18  days.  It  is  not  rare 
to  see  the  expulsion  rather  sooner;  but  it  may  also  come  off  more  tardily 
still,  and  Muller  reports  a  certain  number  of  cases  where  the  foetus  re- 
mained in  the  uterus  many  months,  and  even  up  to  term.  There  are  a 
certain  number  of  cases  of  multiple  pregnancies  where  this  has  occurred; 
we  have  seen  an  example.  One  of  the  twins  dies,  and  the  other  lives, 
and  botii  are  expelled  at  the  same  time.  But,  can  the  dead  foetus  be 
retained  in  the  uterus  beyond  term  or  indefinitely  ?  We  have  developed 
this  point  in  the  article  on  prolonged  gestation,  and  have  seen  that  these 
extremely  rare  cases  should  only  be  admitted  with  reserve.  (Menzies, 
Herrgott. ) 

Symptoms:  1st.  Signs  ])erceive,d  by  the  Mother. — These  are  absence  of 
active  foetal  movements,  signs  only  having  value  as  they  have  been  per- 
ceived quite  clearly  at  first,  but  especially  when  she  noticed  that  they 
gradually  weakened,  presented  irregularities,  and  ceased  sometimes  sud- 
denly. Sometimes,  the  cessation  has  been  preceded  by  an  unusual  exag- 
geration of  the  movements  which  seem  to  be  convulsive.  Some  women 
complain  of  a  sensation  of  coldness  in  the  abdomen,  and  these  sensations,, 
contested  by  most  authors,  have  been  found  once  by  Hourlier.  Schling 
has  established,  by  the  aid  of  thermometric  observation,  that  there  is  con- 
siderable elevation  of  the  uterine  temperature,  compared  to  that  of  the 


DISEASES    OF    THE    FCETUS.  60  ( 

vagina, when  the  foetus  retains  life.  The  abdomen  sinks,  the  uterus — losing 
its  tonicity,  and  not  finding  resistance  in  the  foetaj  parts — collapses  on  its 
lower  segment,  spreads  out,  and  its  centre  tends  to  be  depressed.  The 
mother  feels  the  child  move  about  in  the  abdomen,  take  next  differ- 
ent positions,  and  fall  to  the  side  to  which  she  inclines.  Often,  in  the 
two  or  three  days  Avhich  follow  the  death  of  the  fcBtus,  there  occurs  at 
the  breasts  a  kind  of  congestive  manifestation,  a  kind  of  lacteal  showing, 
which  is  more  or  less  as  the  woman  is  advanced  in  pregnancy,  and  to 
which  succeeds  shrinking  of  the  breasts,  and  sometimes  flowing  of  lacte- 
scent liquid.  Then  all  the  sympathetic  symptoms  of  pregnancy  disap- 
pear, the  vomiting  particularly.  The  abdomea  ceases  to  enlarge,  and  at 
the  same  time  in  some  women  there  is  a  vague  feeling  of  malaise,  charac- 
terized by  loss  of  appetite,  a  feeling  of  lumbago,  of  fatigue,  of  general 
lassitude;  sometimes  in  very  delicate  women^  a  slight  febrile  reaction, 
especially  towards  evening. 

2d.  Signs  perceived  by  the  Obstetrician. — Absence  of  the  heart-sounds, 
established  by  different  trials,  is  the  absolutely  certain  sign,  especially  if 
the  obstetrician  has  clearly  perceived  them  previously.  We  think  this  is 
almost  the  only  sign,  for  those  of  palpation  seem  to  us  more  hypothetical 
than  real,  more  theoretical  than  truly  practical. 

If  the  accoucheur  has  previously  examined  the  patient  during  foetal 
life,  it  may  be  easy  to  reach  a  diagnosis  of  its  death,  but  the  conditions 
are  very  different  when  he  sees  the  woman  only  after  the  death  of  the 
foetus.  Then,  vaginal  touch  and  palpation  give  ns  no  information. 
Stoltz  has  noted  a  sign,  a  sound  isochronous  with  the  mother's  pulse,  a 
species  of  crackling,  which  he  attributes  to  the  decomposition  of  the  liquor 
amnii.     This  sign  is,  however,  not  invariably  present. 

[In  one  case  under  our  observation,  where  the  woman  carried  a  dead 
five  months  foetus  for  a  period  of  four  months,  this  crackling  was  very 
apparent,  but  we  can  hardly  say  that  it  was  isochronous  with  the  mother^s 
pulse.  In  other  instances,  however, we  have  failed  to  hear  the  sign.  To 
us,  the  most  characteristic  physical  sign  of  foetal  death  is  a  flabbiness  of 
the  uterus,  instead  of  resiliency  and  compressibility,  on  the  bi-manual  pal- 
pation, associated,  of  course,  with  the  decrease  in  abdominal  distension, 
and  collapsing  of  the  mammte. — Ed.] 

What  now  may  be  the  appearance  of  the  foetus  after  its  retention  in  the 
uterus  ? 

Lempereur,  Sentex  and  Huge,  have  described  the  changes  well,  and  we 
copy  their  classification: 

"According  to  the  stage  of  foetal  life  at  which  it  has  succumbed,  we  find: 
1.  Dissolution;  2.  Mummification;  13.  Maceration;  4.  Putrefaction;  5. 
Peculiar  alterations,  and  of  doubtful  nature. 

''  Dissolution  is  apt  to  occur  during  the  first  two  months  of  foetal  life. 
The  liquor  amnii  then  appears  more  or  less  milky,  in  a  state  of  emulsion. 


308  A    TREATISE    ON    OBSTETRICS. 

SO  to  speak.     The  placenta  may  continue  to  develop^  and  finally  be  con- 
verted into  one  or  another  form  of  mole." 

Mummification. — Dessication. — "At  the  second  period  of .  intra-uterine 
life  is  a  particular  change,  entirely  distinct  in  form  from  those  which 
precede  or  which  follow.  The  embryo,  endowed  with  a  greater  force  of 
resistance,  provided  with  an  osseous  frame,  frail  and  incomplete,  it  is  true, 
but  nevertheless  solid,  composed  of  newly  organized  elements,  which 
already  have  a  fixed  texture,  does  not  liquefy;  it  preserves  its  first 
form,  except  its  volume,  which  suffers  a  proportional  reduction.  This  is 
mummification,  withering,  emaciation,  contraction,  drying  up  of  the 
anthers.  The  tissues,  yet  soft,  are  condensed  under  the  infiuence  of  this 
prolonged  maceration  in  a  saline  fluid ;  they  diminish  in  volume,  reduced 
to  a  thinner  layer,  in  a  word,  shrivelled  up.  The  color  also  changes  very 
rapidly;  it  becomes  dull,  gray,  yellowish,  tarnished,  and  as  if  cachectic, 
contrasting  clearly  with  the  normal  color,  a  brilliant  dark  rose."  Sentex 
adds  to  this  description  that  the  quantity  of  sanguinolent  serum  exuded 
in  the  different  serous  cavities  is  very  small,  very  dark,  and  the  rose  color 
of  the  eye-humors  hardly  marked.  The  liquor  amnii  in  the  first  degrees 
of  change  exists  still,  but  it  ends  by  disappearing,  leaving "on  the  embryo 
a  dull  grayish  sediment,  analogous  to  the  deposit  of  overflowed  water. 
The  actual  drying  up  may  be  retarded,  in  proportion  as  the  fluid  medium 
remains.  The  embryo  undergoes,  at  the  same  time  with  emaciation,  a 
sort  of  shortening;  besides,  it  is  already  very  small  at  the  time  of  its 
death. 

To  this  change,  in  cases  of  multiple  pregnancy,  is  added  another, 
namely,  flattening.  One  of  the  foetuses  dying  at  this  time,  and  the  other 
continuing  to  develop,  the  dead  foetus,  beaten  down,  is  flattened  like  a 
ginger-bread  image.  It  is  found  at  delivery  joined  to  the  placenta  of  the 
sound  twin,  and  contained  in  a  little  isolated  pouch,  as  we  have  had  occa,- 
sion  to  observe  in  a  clinical  case.  This  is  the  foetus  comjjressa  of  the 
Germans. 

3d.  Maceration. — This  is  by  far  the  most  frequent  of  the  alterations,  and 
the  most  varied  in  its  forms.  It  differs  essentially  from  putrefaction,  in 
that  the  decomposition  proceeds  slowly,  without  production  of  gas,  with- 
out odor,  without  green  cadaveric  tinge,  and  never  involves  the  mother  in 
those  formidable  consequences  to  which  true  putrefaction  exposes  her. 

Euge  and  Sentex  have  described  the  changes  in  these  foetuses,  to  whom 
Martin  has  given  the  name  of  ''foetus  sanguinolentus "  from  its  peculiar 
red-brown  appearance,  in  which  respect  German  authors  follow  him.  In 
France,  such  foetuses  are  called  simply  macerated  { foetus  maceres.) 

The  shape  of  the  cadaver  is  peculiar,  being  flattened  out,  as  it  were,  in 
the  thorax,  while  the  abdomen  projects  like  that  of  a  frog.  The  bones 
have  all  softened  to  such  an  extent  that  the  foetus  collapses,  so  to  speak. 
The  epidermis  is  readily  detachable,  and  is  covered  with  bullse.     The  eel- 


DISEASES    OF    THE   FOETUS.  309 

lular  tissue  is  edematous  and  colored  reddish.  The  foetus  is  so  supple 
that  it  is  often  expelled  doubled  in  two.  The  internal  organs  are  simi- 
larly changed.  The  serous  cavities  are  full  of  bloody  fluid.  The  uterus 
and  the  lungs  are,  of  all  organs,  the  least  altered.  There  is  no  odor  to 
the  foetus  of  a  nauseating  nature.     It  is  simply  stale  and  disagreeable. 

According  to  both  Lempereur  and  Sentex,  the  alterations  are  divisible 
into  periods,  the  changes  being  the  greater  the  more  delayed  the  reten- 
tion.    Sentex  has  followed  these  changes  day  by  day,  as  it  were. 

[Readers  especially  interested  are  referred  to  the  original  articles  of 
Sentex  and  Lempereur,  where  the  details,  as  regards  gross  and  histological 
appearances,  are  strikingly  minute. — Ed.] 

Lempereur;  who  admits  the  prolongation  of  pregnancy  beyond  term, 
says  that,  in  such  cases,  the  foetus  may  present  the  following  alterations: 

3 .  Maceration,  general  breaking  up  of  the  foetus,  and  expulsion  of  all 
the  debris  either  at  a  menstrual  period,  or  during  a  subsequent  preg- 
nancy, or  delivery.  2.  Putrefaction,  if  air  gains  access  to  the  uterus.  3. 
Dessication.     4.  Ossification,  petrification.     5.  Saponification. 

As  for  the  foetal  adnexa,  fibrinous  masses  are  found  in  the  vessels  of 
the  cord,  or  else  simply  liquid  blood  or  recent  coagula.  The  cord  is 
swollen,  of  a  color  like  that  of  the  foetus.  The  placenta  presents,  on  the 
maternal  surface,  a  number  of  smooth- walled  cavities,  containing  yellow 
purulent  masses.  Its  color,  and  that  of  the  membranes  may  be  of  an 
earthy-brown. 

There  is  nothing  unusual  about  the  expulsion  of  the  foetus.  Out  of  77 
macerated  syphilitic  foetuses  observed  by  Euge,  35  presented  by  the  ver- 
tex, 24  by  the  pelvis;  there  were  8  transverse  presentations,  6  of  which 
turned  spontaneously.  Two  points  we  have  noticed  particularly.  One 
being  that  the  membranes  ruptured  slowly,  or  required  to  be  ruptured; 
they  seemed  to  have  spread  considerably.  The  entire  ovum  is  expelled 
more  frequently  than  when  the  foetus  is  living.  On  the  other  hand,  the 
labor  proceeds  more  slowly,  the  uterine  contractions  are  feeble. 

Are  these  alterations  due  to  syphilis,  or  is  maceration  simply  a  post-mor- 
tem change  present  as  well  in  non- syphilitic  infants  ?  Ruge's  researches 
are  absolutely  conclusive.  According  to  him,  78  out  of  94  dead  macerated 
foetuses  are  syphilitic,  but  it  is  not  this  disease  which  causes  the  macera- 
tion, and  induces  the  alterations,  and  the  proof  of  this  assertion  rests  on 
the  fact  that  foetuses  absolutely  not  syphilitic  are  born  macerated,  and 
presenting  identically  similar  changes;  and  further,  in  that  syphilis  is  char- 
acterized rather  by  the  presence  of  peritonitis,  and  hypertrophy  of  the 
liver,  spleen,  lungs,  and,  above  all,  the  bones,  and  these  changes  we  do 
not  find  in  macerated  foetuses.  Maceration,  therefore,  is  caused  by  post- 
mortem changes. 

Putrefaction. — This  is  the  decomposition  established  spontaneously, 
under   certain   conditions,   in  organs  deprived  of   life.       It  causes   pro- 


310  A   TREATISE    OlST    OBSTETEICS. 

dnction  of  new  substances,  especially  vapors  and  very  fetid  gases.  This 
decomposition  only  occurs  when  air  has  penetrated  after  the  rupture  of 
the  membranes.  The  decomposition  goes  on  very  rapidly,  the  three  con- 
ditions essential  to  fermentation  being  present  in  the  uterus,  that  is, 
air,  heat,  humidity. 

The  changes  affect  the  whole  foetus  at  once,  and  are,  as  it  were,  instan- 
taneous. At  the  outset,  there  is  infiltration  of  all  the  superficial  cellular 
tissue  with  gas,  whence  more  or  less  generalized  emphysema,  and  marked 
crepitation  on  palpation.  At  times  the  gases  accumulate  in  the  uterus, 
and  are  expelled  with  a  loud  report.  These  gases  are  poisonous  to  the 
mother.  She  is  seized  with  fever,  chills,  hiccough,  vomiting,  and  may 
shortly  die  if  we  do  not  extract  the  foetus.  The  odor  is  awful,  but  the 
foetal  epidermis  is  never  covered  with  bullse,  as  in  maceration. 

Cadaveric  Rigidity. — Does  this  exist  in  the  foetus  at  the  time  of  birth? 
Casper  says  that  he  has  never  observed  it  in  the  foetus  before  term,  al- 
though it  has  been  noted  in  maternity  hospitals;  and  that,  in  those  born 
at  term,  it  is  of  very  short  duration.  Taylor  has  seen  one  case;  Tourdes 
saw  it,  at  Strasburg,  in  twins  of  five  months;  he  affirms  that  it  may 
occur  in  the  uterus  itself,  and  he  says  that  in  those  cases  where  it  was  not 
noted,  this  was  because  the  duration  was  slight. 

In  England,  cadaveric  rigidity  is  admitted  by  G-rigg,  Young,  Parkin- 
son, but  denied  by  Thompson.  Bailly  grants  it,  and  has  always  found  it. 
Dagincourt,  who,  to  the  other  observations,  adds  two  cases  of  Budin% 
and  one  personal,  says  that  muscular  rigidity  is  due  to  coagulation  of  the 
myosin,  under  the  influence  of  the  post-mortem  acid  reaction  of  the 
muscles.  The  foetal  muscle  does  not  differ  in  composition  from  that  of 
the  adult,  and,  therefore,  may  be  presumed  to  act  similarly  under  similar 
conditions. 

The  question  cannot  as  yet  be  answered.  The  two  hypotheses,  cadaveric 
rigidity,  and  cadaveric  spasms,  have  each  weighty  arguments  in  their 
favor.  Are  the  cases  of  Thompson  and  of  Bailly  analogous  to  those  to 
which  Taylor  has  given  the  name  of  spasm  ?  We  believe,  with  Pinard 
and  Dagincourt,  in  a  true  cadaveric  rigidit}^,  for,  as  Pinard  justly  says,  in 
case  of  convulsions,  we  do  not  observe  flexion,  but  extension  of  the  limbs, 
and  in  all  the  cases  cited  of  cadaveric  ■  rigidity,  the  foetus  has  been  in  a 
state  of  flexion. 


CHAPTEE  Y. 
MISCAEKIAGE. 

rpHE  term  miscarriage  is  applied  to  the  expulsion  of  the  product  of  con- 
-^  ception  before  it  is  viable.  It  is  seen  at  once  that  this  diiiers  from 
premature  labor,  which  means  the  expulsion  of  the  product  of  conception 
before  term,  but  where  the  foetus  is  viable.  In  this  respect  accoucheurs 
differ  from  the  rulings  of  the  law.  The  latter  states  that  the  foetus  is 
viable  after  the  sixth  month,  while  the  former  contend  that  it  is  not  so  till 
the  seventh.  It  is  our  belief,  then,  that  miscarriage  consists  in  the  expul- 
sion of  the  foetus  during  the  six  first  months  of  pregnancy.  This  foetus 
may  be  born  dead  or  alive,  but  its  development  will  not  admit  of  life — it 
is  not  viable.  In  certain  exceptional  cases,  foetuses  of  less  than  seven 
months  may  live,  but  these  cases  are  of  such  rarity  that  we  are  justified 
in  the  division  which  we  have  made.  Before  seven  months,  therefore, 
miscarriage;  after  seven  mouths,  premature  labor.  To  the  exceptional 
cases  which  have  been  recorded,  we  can  add  another.  A  woman  last 
menstruated  the  tenth  of  March;  was  delivered  the  twenty-eighth  of 
September,  that  is  to  say,  twelve  days  before  the  seventh  lunar  month. 
The  child  survived. 

Although  we  make  this  division,  it  should  be  understood  that  miscar- 
riage from  the  third  to  the  fourth  month  is  a  very  different  affair  from 
miscarriage  at  the  fifth  or  sixth  month.  While  during  the  early  months, 
the  first  three  in  particular,  the  phenomena  of  miscarriage  are  special  and 
peculiar,  from  the  fourth  month  on,  these  phenomena  approach  more 
and  more  in  character  labor  at  full  term.  Struck  by  these  peculiarities, 
the  older  writers,  and  certain  modern,  (we  would  instance,  in  particular 
Guillemot),  made  three  divisions  of  miscarriage:  1.  Ovular  miscarriage. 
2.  Embryonic.  3.  Foetal.  Why  this  division?  It  is  because  each  cor- 
responds to  a  certain  stage  of  development  of  the  ovum,  and  such  distinc- 
tion, while  subtile,  has,  practically,  certain  advantages. 

Ovular  miscarriage  includes  the  first  three  to  four  weeks  of  the  life  of 
the  ovum. 

Embryonic  miscarriage  extends  from  the  end  of  the  first  month  to  the 
end  of  the  third. 

Foetal  miscarriage  from  the  fourth  to  the  seventh  month 

Coincidently,  indeed,  with  the  development  of  the  ovum,  it  unaergoes 
modifications  in  structure,   which  necessitate  infinite  differences  in  its 


312  A    TREATISE   ON"    OBSTETRICS. 

expulsion;  and  even  as  we  were  able  to  say  of  labor  at  term,  that  not  one 
resembled  the  other,  the  same  may  be  said  of  miscarriage.  When  we 
study  the  phenomena  of  miscarriage,  we  must  remember  that  we  are 
dealing  with  a  number  of  factors.  Kunecke,  in  G-ermany,  makes  four: 
1st.  Mechanical  modifications.  2d.  Organic.  3d.  Dynamic.  4th.  Plas- 
tic. We  make  of  these,  two:  The  modifications  which  concern:  1st.  the 
ovum,  3d.  the  uterus. 

On  the  side  of  the  ovum  these  modifications  are  enormous,  from  the 
day  when  it  arrives,  as  a  new  organism,  in  the  womb,  up  to  the  end  of 
the  third  month;  so  great,  indeed,  that  it  is  impossible  to  compare  the 
ovum  of  the  first,  second,  and  third  month  together. 

During  the  first  month,  the  ovum,  engrafted  on  the  uterine  mucous 
membrane,  which  swells  around  it,  so  as  to  constitute  what  is  termed  the 
decidua  refiexa,  is  surrounded  entirely  by  the  villi  of  the  chorion,  which 
develop  over  its  surface.  It  is  composed  already  of  its  two  membranes, 
the  amnion  and  the  chorion,  and  the  uterine  mucous  membrane  may  be 
decomposed  into  three  portions,  parietal  •  decidua,  decidua  refiexa,  and 
mucous  membrane  between  placenta  and  uterus,  or,  better  still,  between 
uterus  and  ovum.  There  is  still  no  cavity  in  the  ovum.  It  is  being 
formed.  When  removed  from  the  decidua,  the  ovum  looks  like  a  small 
body  roughened  by  the  projection  of  a  number  of  appendages,  one  longer 
than  the  others,  at  the  centre  of  which  is  found  the  amnion,  containing 
the  microscopic  embryo,  so  to  speak.  This  little  ovum  is  surrrounded  by 
a  second  membrane,  thicker,  and  more  voluminous,  in  which  it  is  almost 
lost,  and  which  is  no  other  than  the  uterine  mucous  membrane,  in  two 
portions,  the  one  applied  directly  to  the  ovum,  the  decidua  refiexa,  the 
other  larger,  and  separated  from  the  former  by  a  space  filled  with  gelatin- 
ous matter,  more  or  less  liquid,  and  this  is  the  parietal  mucous  mem- 
brane. This  gelatinous  matter,  which  disappears  later,  is  the  hydroperion. 
The  whole  is  surrounded  by  clots,  more  or  less  dense. 

From  the  fifth  week,  the  ovum  is  composed  of  three  distinct  layers. 
An  internal,  the  amnion,  which,  growing  away  from  the  embryo,  forms 
a  cavity  which  fills  up,  more  and  more,  with  the  amniotic  fiuid.  An 
external,  the  chorion,  furnished  with  ramifying  villi,  which  cover  the 
whole  of  the  ovum,  and  penetrate  into  the  mucous  membrane  of  the 
uterus.  A  middle,  the  allantois,  which,  thinning  out  more  and  more  as 
it  tends  to  disappear,  becomes  a  vesicle,  a  cellular  layer,  which  brings  the 
iTmbilical  vessels  to  the  finest  radicles  of  the  chorionic  villi.  The  whole 
is  surrounded  by  the  uterine  decidua.  From  this  time  forth,  the  vital 
conditions  of  the  ovum  change.  While  up  to  now,  it  is  the  umbilical 
vesicle  which  has  furnished  nourishment  to  the  ovum  and  the  embryo, 
from  the  moment  when,  through  the  allantois,  the  umbilical  vessels 
reach  the  mucous  membrane  of  the  uterus,  it  is  these  which  supply 
nourishment  to  the  foetus,  and  we  are  going  to  witness  the  formation  of  a 


MISCARRIAGE.  313 

new  organ,  the  placenta,  wliicli  becomes  the  centre  of  foetal  nutrition. 
The  umbilical  vesicle  atrophies  and  collapses,  and  it  is  to  be  founds  be- 
tween the  amnion  and  the  chorion,  as  a  little  vesicle  adhering  to  the 
embryo  by  a  long  obliterated  pedicle,  the  omphalo-mesenteric  cord,  in 
which  arc  seen  traces  of  the  primitive  vessels  of  the  embryo.  Before, 
however,  the  placenta  is  formed,  the  ovum  undergoes  mt^^ny  other  changes, 
which  concern  in  particular  the  amnion  and  the  chorion. 

At  first  adhering  to  the  embryo,  from  which  it  is  an  offshoot,  except  at 
the  level  of  the  ventral  opening,  the  amnion  recedes  more  and  more 
towards  the  dorsal  and  ventral  portion,  forming  thus  a  complete  sac  in 
which  the  embryo  is  plunged,  a  sac,  which,  at  its  ventral  surface,  is  going 
to  form  an  addition  to  the  orgatis  which  issue  from  the  abdominal  cavity 
of  the  foetus  to  form  the  umbilical  cord.  It  thus  gradually  meets  the 
chorion,  and  is  separated  from  it  only  by  the  cellular  layer,  which  is  the 
remnant  of  the  allantois.  The  amnion  and  chorion  then  grow  simulta- 
neously, and,  the  amniotic  fluid  increasing,  the  decidua  reflexa  is,  in  turn, 
pushed  towards  the  parietal  decidua,  and,  towards  the  fourth  month, 
this  decidua  joins  the  parietal  and  merges  into  it. 

During  this  period,  what  becomes  of  the  villosities  which  we  have  seen 
covered  the  entire  ovum  ?  While  those  which  cover  the  side  of  the  ovum, 
towards  the  parietal  decidua  develop  further  to  form  the  placenta,  those 
which  correspond  to  the  decidua,  reflexa,  pushed  aside  by  the  growth  of 
the  ovum,  are  flattened  out,  and  their  vessels  obliterated.  These  villi 
atrophy,  and,  when  the  decidua  reflexa  and  parietal  meet,  these  villi 
exist  no  longer,  so  to  speak,  and  the  ovum  remains  in  communication 
with  the  mother  only  by  the  placental  villi,  which,  bathing  in  the  uterine 
sinuses,  become  the  medium  of  exchange  in  nutritive  substances  which 
go  towards  the  development  of  the  foetus.  As  the  ovum  developes,  these 
utero-placental  adhesions  become  the  stronger,  so  strong  in  certain  in- 
stances that  we  are  obliged  to  detach  the  placenta  even  at  term.  The 
nearer  we  approach  term  the  feebler,  normally,  become  these  adhesions, 
and  consequently,  the  greater  the  ease  with  which  the  ovum  detaches 
itself  from  the  uterus. 

After  three  months  and  a  half  to  four  months,  miscarriage  becomes  a 
labor  in  miniature.  The  placenta  is  fully  formed,  the  ovum  has  definite 
structure.  The  uterine  mucous  membrane  has  sent  solid  epithelial  pro- 
longations between  the  villi,  so  as  to  intimately  attach  the  ovnm  to  the 
uterus,  and  protect  it  against  destruction.  While  prior  to  this,  the  ovum 
lived,  so  to  speak,  by  its  entire  periphery,  under  the  influence  of  the  de- 
velopment of  the  amnion,  and  of  its  greater  distension  by  the  liquor  amnii, 
the  distended  chorion  loses  its  villi,  and  thins  out,  and,  at  the  same  time, 
displaces  before  it  the  decidua  reflexa,  which  becomes  similarly  thinned 
out.  At  the  end  of  the  fourth  month,  the  parietal  decidua  and  the  re- 
flexa unite,  and  the  ovum  exists  as  it  remains  till  the  end  of  pregnancy. 


314  A   TREATISE    ON    OBSTETRICS. 

Attaclied  to  the  uterus  by  tlie  placenta,  the  ovum  is  composed  of  the 
amnion  and  the  chorion,  tliin  membranes,  of  great  tenuity,  and  it  is 
covered  by  tlie  decidua.  In  tlie  liquor  amnii  swims  the  foetus,  attached 
to  the  cord,  which  gains  in  size  and  in  length.  It  is  especially  important 
to  remember  that  the  placenta  is  relatively  larger  than  the  foetus,  and, 
above  all,  more  solid  and  resisting. 

The  second  factor  consists  in  the  modifications  of  the  uterus. 
These,  we  have  seen,  concern  both  the  cervix  and  the  body,  and 
are  characterized  by  increase  in  size,  in  capacity,  in  weight,  by 
change  in  form,  in  situation,  in  consistency,  in  thickness,  and  above 
all  by  modifications  in  the  serous,  muscular,  and  mucous  layers. 
These  changes,  and  modifications,  we  have  already  sufficiently  noted. 
Let  us  recall  only  the  transformation  of  the  inter-utero  placental 
mucous  membrane  into  a  species  of  spongy  tissue,  the  whole  of  the  in- 
terstices of  which  are  filled  with  blood  in  which  the  villi  of  the  placenta 
are  plunged,  and  are  united  to  this  tissue  by  epithelial  bands  from  the 
mucous  membrane;  and  further,  let  us  recall  the  progressive  develop- 
ment of  the  muscular  tissue,  which,  through  the  exercise  of  its  funda- 
mental property,  contractility,  becomes  the  active,  essential  agent,  which 
expels  the  foetus.  Let  us  add,  finally,  the  shedding  of  the  uterine  mucous 
membrane,  a  process  which  to-day,  it  is  admitted,  concerns  not  alone  the 
parietal  decidua,  but  also  the  superficial  part  of  the  inter-utero-placental 
mucous  membrane. 

It  is  apparent,  now,  why  it  is  that  miscarriage  may  be  different,  ac- 
cording to  the  period  of  gestation  at  which  it  occurs,  and  the  conditions 
which  determine  it. 

Having  stated  the  above  general  views,  we  begin  at  once  the  study  of 
miscarriage. 

Frequency. — Is  miscarriage  a  frequent  accident?  According  to  hospi- 
tal statistics,  it  is  rare,  but  nevertheless  it  is  of  very  common  occurrence. 
The  reason  for  this  discrepancy  is  that  miscarriage  during  the  early  weeks 
is  generally  not  noticed.  Many  women  believe  that  the  menses  are  sim- 
ply retarded,  and  although  they  may  suspect  a  miscarriage  from  the  pas- 
sage of  clots,  or  crampy  pains  greater  than  they  usually  suffer  when  men- 
struating, they  do  not  consult  a  physician,  and  even  if  they  did  there 
would  still  be  doubt,  seeing  that  the  ovum  is  not  likely  to  be  found  in 
the  clots  which  have  been  passed.  Even  if  the  woman  knows  she  is  mis- 
carrying, she  does  not  go  to  the  hospital,  but  household  remedies  are  usu- 
ally administered.  It  is  only  in  his  private  practice,  therefore,  that  the 
physician  can  really  be  certain,  and  even  then  only  in  part,  of  the  mis- 
carriage. The  sam.e  uncertainty  exists  in  regard  to  the  frequency  at 
different  periods  of  pregnancy.  While  many  authors  believe  that  miscar- 
riage occurs  oftener  from  the  third  to  the  fourth  month,  Jacquemier,  De- 
paul,  Cazeaux,  state  that  this  is  true  only  in  the  first  two  or  three  months. 


MISCARRIAGE,  315 

Depaul  is  even  more  precise,  and  places  the  jieriod  of  greatest  frequency 
at  two  and  a  half  to  three  and  a  half  months,  from  thence  diminishing  in 
frequency  up  to  term.  Opposed  to  this  opinion  is  Jacquemier,  who,  with- 
out agreeing  fully  with  Madame  Lachapelle,  in  whose  experience  the  sixth 
month  was  the  time  of  election,  rather  than  earlier  in  pregnancy,  declares 
that  at  this  month  it  is  settled  that  miscarriage  occurs  with  certainly  as 
great  frequency  as  in  the  earlier  months.  This  view,  while  true  of  pre- 
mature labor,  appears  to  us  exaggerated  as  applied  to  miscarriage,  and 
we  believe  with  Depaul  that  the  latter  is  of  greatest  frequency  from  two 
months  to  three  and  a  half.  Still  we  are  speaking  now  purely  of  certified 
miscarriages,  and  it  still  holds  true  that  many  an  ovum  is  shed  unnoticed 
during  the  first  four  to  six  weeks;  this  is  not  astonishing  when  we  remem- 
ber that  it  is  only  at  three  months,  to  three  and  a  half,  that  the  placenta 
is  developed,  and  that  up  to  this  time  the  feebleness  of  the  adhesions 
which  bind  the  ovum  to  the  uterus,  and  the  ease  with  which  extravasa- 
tions may  take  place  between  the  chorion  and  the  decidua  reflexa,  render 
it  an  easy  matter  for  the  ovum  to  be  disturbed. 

Is  miscarriage  more  frequent  in  case  of  female  than  of  male  foetuses  ? 
Morgagni  and  Desormeaux  have  so  held,  but  their  opinion  is  based  on 
absolutely  no  statistical  data.  Jacquemier  is  in  doubt  on  this  point;  Ca- 
zeaux  is  inclined  to  agree  with  Desormeaux,  because  at  term  the  propor- 
tion of  boys  to  girls  is  as  1 6  to  15,  and  therefore  it  is  possible  the  miscar- 
riage of  females  may  be  more  frequent. 

Causes. — These  may  depend  on:  1st.  The  father;  2d.  The  mother;  3d. 
The  ovum;  4th.   Criminal  attempts  or  external  violence. 

1st.  The  father  may  be  the  cause  of  miscarriage  through  constitutional 
or  acquired  means.  Men  too  young  or  too  old;  those  whose  constitution 
is  Aveakened  by  debauchery,  or  excesses,  or  disease,  these  are  likely  to  be- 
get a  fcetus  not  fit  for  development.  Further,  the  influence  of  syphilis 
in  the  father  is,  to-day,  admitted  universally,  and  the  lesions  presented 
by  the  foetus  are  so  distinctive  in  such  cases  that  they  point  at  once  to 
syphilis  of  the  father. 

2d.  In  women  who  are  very  young,  with  body  incompletely  developed, 
and  menstruation  not  normally  established,  with  tissues  delicate  and  fee- 
ble; in  women  who  are  old,  with  tissues  dense,  and  brittle — in  these 
miscarriage  is  frequent.  Depaul  absolutely  denies  this,  but  Jacquemier 
affirms  that  it  is  not  unusual  to  see  women  miscarry  with  the  greatest 
ease  the  nearer  they  are  to  the  age  when  aptitude  for  conception  usually 
ceases.  We  have,  ourselves,  seen  three  children,  of  thirteen,  thirteen  and 
a  half,  and  fourteen  years,  respectively,  confined  at  term,  but  these  chil- 
dren in  their  physical  development  were  in  advance  of  their  age. 

As  for  the  temperament  of  the  mother,  it  has  been  claimed  that  the 
nervous,  the  bilious,  the  sanguine,  were,  in  turn,  causes.  This  seems  to 
be  true,  in  particular  of  the  latter.     Many  women,  indeed,  who  are  of 


316  A    TREATISE    OlST    OBSTETRICS. 

full  habit,  and  lose  profusely  at  their  periods,  miscarry  readily,  and  this 
usually  at  a  time  which  coincides  with  the  menstrual  epoch.  As  for  the 
form  of  temperament,  nothing  has  been  proved;  indeed  the  nervous  is 
often  dependent  on  functional  uterine  disease,  and  to  this,  therefore, 
must  we  look  for  explanation  of  the  miscarriage. 

On  high  temperature  as  a  cause  Depaul  attaches  much  importance. 
In  warm  climates,  uterine  hemorrhages  are  of  common  occurrence,  and 
these  in  turn  may  provoke  miscarriage.  We  refer  here  only  to  climatic 
temperature,  and  not  to  elevation  in  the  mother,  the  result  of  disease. 

In  mountainous  countries,  further,  miscarriage  is  frequent,  and  we  are 
told  by  Saucerotte  and  Jourdanet  that  the  women  of  such  regions  are 
accustomed  to  resort  to  the  valleys  in  order  to  avoid  miscarriage. 

Madame  Boivin  and  Madame  Lachapelle  admit,  as  a  further  cause,  epi- 
demic influence,  but,  although  such  is  the  case  with  animals,  it  cannot, 
be  considered  so  in  the  human  female.  It  is  especially  during  famines 
and  sieges  that  this  cause  has  been  supposed  to  hold,  but,  evidently,  here 
there  are  other  factors  at  work. 

Finally,  there  are  a  number  of  women  in  whom  there  exists  a  habit  of 
aborting,  either  because  the  genital  system  functionates  badly,  or  because 
the  menses  are  irregular,  often  scanty  or  painful,  or  else,  because  the  geni- 
tal system  seems  to  lack  vigor.  These  women,  pale,  feeble,  and  subject 
to  lencorrhoea,  possess,  frequently,  this  trait  in  common  with  those  of  the 
sanguine  temperament,  that  they  suffer  from  menorrhagia;  but  they  are 
always  irregular  in  menstruation.  Stolz  has  further  pointed  out  that 
stout  women  are  often  sterile,  and  that,  when  they  do  conceive,  they  are 
predisposed  to  miscarriage,  doubtless  because  local  nutrition  is  at  fault, 
and  the  fluids  intended  to  nourish  the  foetus  are  insufficient  for  its  de- 
velopment. 

Every  acute  or  even  chronic  disease  of  the  mother  may  become  a  cause 
of  miscarriage,  when  such  diseases  affect  profoundly  the  respiration,  the 
circulation,  or  the  temperature.  Of  these  diseases,  there  are  certain 
which  act  more  powerfully  than  others.     (See  Pathology  of  Pregnancy.) 

Diseases  of  the  uterus:  metritis,  endometritis,  interstitial,  and  sub- 
mucous fibroids,  versions,  flexions,  organic  disease  of  the  cervix,  espe- 
cially of  the  body.  Still  further:  adhesions  of  the  broad  and  round  liga- 
ments, of  the  tubes  and  ovaries,  since  they  may  interfere  with  the 
development  of  the  uterus.  Again,  inflammations  of  the  bladder,  of  the 
rectum;  neighboring  tumors,  pelvic  deformities,  which  prevent  the  regu- 
lar development  of  the  uterus  or  retrovert  it. 

Finally,  there  are  certain  women  who,  without  special  cause,  miscarry 
over  and  over  again,  and  it  would  seem  as  though  in  them  there  existed 
special  irritability  of  the  uterine  fibre.  The  sphincter  of  the  uterus  seems 
to  be  weakened,  and,  when  pregnancy  ensues,  the  least  effort  overcomes 
it.     This  has  been  called  laxity  of  the  fibres  of  the  cervix.     This  irrita- 


MISCAKKIAGE.  S 1 7 

bility  of  the  uterus  determines  the  premature  appearance  of  contractions, 
the  cervix  yields,  the  membranes  rupture,  and  miscarriage  occurs,  without 
other  cause  than  this  excessive  irritability  of  the  uterine  fibres. 

Jacquemier  has  studied,  in  particular,  uterine  congestion  as  a  frequent 
cause  of  miscarriage,  and  we  reproduce  his  views:  "Active  or  passive 
congestions  of  the  uterus  are  the  most  frequent  causes  of  miscarriage. 
Tliey  excite  the  uterus  to  contract  abnormally,  and  determine  often  ex- 
travasations between  the  uterus  and  the  placenta.  These  extravasations 
are  the  result  of  rupture  of  the  vessels  which  go  from  the  uterus  to  the 
placenta.  Indeed,  in  many  miscarriages,  the  determining  factor  is  the 
existence  of  hemorrhage,  or  its  manifestation  internally  or  externally. 

"All  stout  women  are  not  equally  predisposed  to  uterine  congestion. 
Those  who  are  plethoric,  and  have  hemorrhages  apart  from  pregnancy, 
are  equally  more  inclined  to  puerperal  hemorrhage  than  others.  The 
very  existence  of  pregnancy  inclines  to  further  congestion.  This  organ 
is  then  much  more  vascular  than  before.  New  blood-vessels  are  sent 
ramifying  through  the  placenta  and  the  decidua,  and  these  vessels  are 
soft  in  texture,  and  easily  torn.  The  moderate  and  regular  contraction 
of  the  uterine  muscular  fibre  for  the  moment  empties  the  uterus  of  the 
excess  of  blood  which  distends  these  vessels;  but  let  this  contraction  be 
(3ver  strong,  spasmodic,  or  local,  and  the  connection  between  the  ovum 
and  the  uterus  may  be  changed,  and  hemorrhage  occur  between  it  and 
the  uterus.  Further,  it  should  be  remembered  that  at  the  dates  corre- 
sponding to  the  suppressed  menstrual  periods,  the  uterus  is  still  further 
temporarily  congested,  and  every  accoucheur  has  noted  the  frequency  of 
miiscarriage  at  dates  coinciding  with  the  menstrual  cycle." 

It  remains  to  note  as  causes  of  miscarriage:  tight  clothing,  which  in- 
terferes with  the  abdominal  circulation,  moral  emotions,  mechanical  shak- 
ing, such  as  results  from  carriage  or  horseback  riding;  external  trauma- 
tism, which  acts  either  directly  on  the  uterus,  or  indirectly  by  determin- 
ing congestion  of  the  organ;  violent  muscular  efforts;  operations  on 
the  genital  organs;  efforts  at  criminal  abortion;  drugs  which  have  an  oxy- 
tocic influence.  Many  of  these  causes,  as  Jacquemier  truly  says,  only 
suffice  when  they  act  with  great  intensity,  or  in  women  who  are  predis- 
posed to  miscarry. 

Causes  7'esiding  in  the  Ovum. — Here  are  included  all  the  diseases  of 
the  placenta,  of  the  membranes,  of  the  cord,  of  the  foetus  itself.  Let  us 
only  recall  the  alterations  in  the  placenta,  the  hemorrhages  and  their 
results,  the  alterations  in  the  villi,  the  premature  rupture  of  the  mem- 
branes, shortness  of  the  cord,  anomalies,  knots,  stenosis  or  phlebitis  of 
the  vessels  of  the  same;  in  a  word  all  the  diseases  which  may  cause  the 
death  of  the  foetus. 

Symptoms. — One  great  fact  dominates  the  symptomatology  of  miscar- 
riage, and  this  is  uterine  hemorrhage,  profuse  or  moderate.     At  times. 


318  A    TREATISE    OlST    OBSTETRICS. 

says  Jacqiiemier,  it  is  the  provoking  cause  of  miscarriage;  again,  it  is  not 
caused  by  the  contractions  of  the  uterus,  but  the  separation  and  the  ex- 
pulsion of  the  ovum  are  accompanied,  from  the  start,  by  a  slight  flow 
which  frequently  assumes,  in  character,  the  proportions  of  a  hemorrhage. 

The  causes  of  miscarriage  produce  the  following  three  results:  1st. 
Either  the  ovum  is  abruptly  severed  from  its  attachments,  and  the  mis- 
carriage is  an  immediate  phenomenon.  This  is  rare;  2d.  Or  uterine  con- 
tractions, premature,  are  determined,  and  there  results  immediate  sepa- 
ration of  the  ovum;  3.  Or,  finally,  there  results  uterine  congestion,  which 
entails  rupture  of  blood-vessels,  and  separation  of  the  placenta.  Then 
there  follow  uterine  contractions,  and  these  are  secondary,  consecutive. 
This  is  the  most  frequent  form,  and  it  is  here  that  are  observed  the  pro- 
dromic  phenomena  of  miscarriage. 

Signs  of  impending  Miscarriage.  — If,  in  certain  instances,  miscarriage 
results  suddenly,  without  the  women  being  aware  of  it,  except  through 
the  appearance  of  the  ovum,  this  is  not  always  the  case,  and  there  are 
usually  prodromic  signs,  more  or  less  marked,  and  which  vary  with  the 
etiological  factor  at  work.  Often  these  symptoms  are  simply  an  exagger- 
ation of  those  common  to  the  menstrual  period,  a  feeling  of  malaise,  of 
general  weakness,  accompanied  by  pain  in  the  loins,  radiating  to  the  rec- 
tum and  to  the  bladder.  At  the  same  time,  the  touch  reveals  certain 
changes  in  the  cervix,  accompanied  by  flaccidity  of  the  vagina  and  in- 
creased secretion.  Three  circumstances,  above  all,  influence  these  symp- 
toms, which  vary  accordingly:  1st.  Imminence  of  hemorrhage;  3d.  Causes 
acting  directly  or  indirectly  on  uterine  contractility;  3d.  The  death  of 
the  foetus. 

Where  hemorrhage  is  imminent,  plainly  it  is  congestive  phenomena 
which  are  in  the  foreground;  phenomena  not  limited  exclusively  to  the 
abdominal  organs,  but  affecting  the  whole  body,  as  evidenced  by  the  ac- 
celerated circulation,  by  the  force  and  fullness  of  the  pulse  beat,  by  con- 
gestion of  the  face,  or  again,  by  irregular  chills,  by  pain  and  tension  in 
the  loins  and  the  abdomen,  increased  by  the  least  fatigue.  Earely,  true 
uterine  contractions  exist;  usually  the  woman  is  conscious  of  these,  with- 
out being  able  to  exactly  locate  them.  Often  a  slight  show  appears,  ceases 
under  rest  or  appropriate  treatment,  and  the  pregnancy  goes  on  to  term. 
Again  these  symptoms  may  recur,  and,  at  length,  after  two  or  three  simi- 
lar recurrences,  the  ovum  is  expelled.  These  congestive  symptoms  al- 
most always  coincide  with  a  menstrual  epoch,  and  similarly  the  miscar- 
riage occurs. 

In  other  instances,  instead'of  congestive  phenomena,  the  signs  are  char- 
acteristic of  uterine  irritability,  merging,  on  the  slightest  provocation, 
into  contraction.  The  least  fatigue,  the  least  effort,  results  at  once  in 
pain  in  the  loins  and  abdomen,  with  sensation  of  weight  in  the  rectum 
and  bladder,  and,  finally,  true  uterine  contractions,  appreciable  often  to 


MISCAKRIAGE.  319 

the  hand  where  the  woman  is  tliin^  or  tlie  uterus  has  risen  above  the 
brim,  set  in.  In  such  cases,  the  cervix  is  less  changed,  remaining  firm, 
and  resisting,  and  it  is  only  when  the  miscarrage  is  well  under  way,  that 
blood  appears. 

When  the  foetus  is  dead,  the  phenomena  are  far  different.  When  the 
foetus  has  developed  sufficiently  to  allow  us  to  feel  its  movements,  and  to 
hear  the  pulsations  of  its  heart,  we  may,  so  to  speak,  be  present  at  its 
death,  by  folloAving  the  slow  disappearance  of  these  signs  of  foBtallife;  and 
then  it  is  that  the  women  experience  all  those  sensations  which  we  have 
referred  to  when  speaking  of  the  death  of  the  foetus.  But,  when  the  ovum 
has  not  reached  such  a  developmental  stage  as  to  allow  us  to  appreciate 
the  signs  of  life,  the  diagnosis  becomes  difficult,  and  the  precursory  phe- 
nomena are  obscure,  and  not  easy  to  differentiate.  It  is  exceptional,  in 
such  instances,  for  miscarriage  to  follow  at  once  on  the  death  of  the  foetus. 
Usually  it  is  only  at  the  end  of  six  to  ten  days,  and.  often  longer,  that 
the  foetus  is  expelled.  Where  the  fcetal  death  results  from  acute  feb- 
rile disease  of  the  mother,  miscarriage,  on  the  other  hand,  follows  soon, 
and  the  precursory  signs  are  masked  under  the  symptom  the  outcome  of 
the  maternal  disease.  When,  however,  the  foetus  succumbs  to  a  slow  in- 
toxication, or  from  accidental  cause,  then  the  precursory  signs  are  sharply 
accentuated.  To  the  positive  signs  of  foetal  death,  are  joined  symptoms 
from  the  side  of  the  mother;  paleness,  feebleness,  lassitude,  a  sensation  of 
something  abnormal.  At  times  a  gentle  evening  rise  of  temperature,  a 
feeling  of  weight  in  the  pelvis,  the  cessation  of  the  sympathetic  signs  of 
pregnancy,  swelling  of  the  breasts,  exudation  of  a  milky  fluid  from  the 
nipples,  followed  by  decrease  in  size  of  these  organs;  relaxation  of  the 
cervix,  patency  of  the  external  os;  above  all,  the  appearance  of  a  red  dis- 
charge, which  may  increase  markedly,  and  become  sero-sanguinolent  of 
stale  and  disagreeable  odor.  Again,  this  discharge  is  intermittent,  ceas- 
ing for  a  few  hours,  or  days,  and  reappearing  with  greater  intensity. 
From  time  to  time,  appear  true  uterine  contractions,  at  first  gentle,  and 
then  intense,  and  followed  by  greater  discharge.  Then  these  contractions 
cease,  and  all  is  quiet  and  normal,  until,  at  last,  labor  frankly  sets  in. 

Symptoms. — Two  phenomena  always  accompany  miscarriage:  hemor- 
rhage, and  uterine  contraction.  These  symptoms  are  variable,  according 
to  the  stage  of  pregnancy,  and  according  to  the  life  or  death  of  the  foetus. 
When  the  miscarriage  occurs  during  the  early  weeks  of  pregnancy, 
whether  the  foetus  be  dead  or  alive,  makes  no  difference.  The  uterine 
tissue  is  denser  than  the  normal,  but  the  muscular  fibres  have  only  be- 
gun to  develop.  It  is  not  the  contractions  of  the  uterus  which  are  going 
to  cause  the  shedding  of  the  ovum,  but  it  is  uterine  congestion  and  the 
resultant  hemorrhage  which  produce  this  phenomenon,  and  dilatation 
of  the  cervix  occurs  but  imperfectly.  As  at  the  time  of  menstruation,  the 
cervical  canal  opens,  and  becomes  patulous,  but  without  true  dilatation. 


320  A  TEEATISE    ON    OBSTETRICS. 

and  clots  and  ovum  are  so  soft  that  they  readily  pass  through  this  canal. 
The  resistance  offered  is  lessened  by  the  softening  of  the  uterine  tissue, 
and  it  is  not  the  ovum  which  gives  rise  to  trouble,  but  the  clots  which 
surround  it.  The  ovum  is  lost  within  these  clots,  and  the  miscarriage 
is,  usually,  soon  accomplished.  The  hemorrhage,  often  no  more  than  is 
lost  at  the  menstrual  periods,  is  accompanied,  or  at  once  followed,  by  a 
few  colic-like  pains,  or  uterine  contractions,  and  these  suffice  to  expel  the 
ovam.  If  the  process  lasts  over  long,  occasionally,  it  is  because  the  uter- 
ine mucous  membrane  is  detached  with  difficulty,  often  in  shreds,  as  is 
seen  in  pseudo-membranous  dysmenorrhoea,  which  has  often  been  mis- 
taken for  miscarriage.  At  times,  shreds  are  passed  for  a  few  days,  ac- 
companied each  time  by  hemorrhage  and  contraction;  then  the  discharge 
becomes  sero-sanguinolent  and  serous,  and  the  miscarriage  is  ended.  The 
cervix  remains  patulous  for  a  few  days,  but  it  retains  its  length,  and  the 
uterus  quickly  regains  its  form,  consistency,  and  normal  dimensions.  In 
such  cases,  the  ovum  is  passed  entire,  and,  if  it  seem  torn,  this  is  because 
the  scarcely  formed  cavity,  between  the  decidua  reflexa  and  parietalis,  is 
mistaken  for  the  cavity  of  the  ovum.  The  shreds,  which  are  seen,  do 
not  belong  to  the  ovum,  but  to  the  decidua  which  the  uterus  furnishes  to 
the  ovum  as  an  outer  covering. 

Miscarriage  from  the  first  to  the  second  month,  differs  notably  from 
that  of  the  early  weeks.  The  uterus,  indeed,  has  developed  with  the 
ovum,  has  become  proportionately  hypertryphied,  especially  in  its  mus- 
cular tissue,  since  the  mucous  coat  is  intended  to  be  shed  with  the  ovum, 
and  replaced  by  another.  Miscarriage  here,  then,  consists  in:  1st.  Sep- 
aration of  the  ovum.  2d.  Separation  of  the  mucous  membrane.  3d. 
Expulsion  of  the  ovum. 

At  this  period  still,  spontaneous  miscarriage  frequently  occurs,  because 
the  bands  which  unite  the  ovum  to  the  uterus  are  very  fragile,  and  it  is, 
in  particular,  at  the  menstrual  epoch  that  the  accident  occurs.  The  mis- 
carriage, may  occur  entire — that  is  to  say,  the  ovum  may  be  expelled  en 
masse,  intact,  or  with  ruptured  membranes.  If  the  catamenial  or  other 
congestive  factor  be  strong,  hemorrhage  results,  and  the  blood,  escaping 
into  the  uterine  cavity,  tears  these  fragile  bands,  often  even  tears  the 
chorion,  penetrates  this  membrane,  reaches  the  amnion,  ruptures  it,  and 
gains  the  interior  of  the  ovum,  as  is  proved  by  the  cases  of  Breschet, 
Dance,  Blot,  Dohrn,  Hegar,  Henning,  etc.  The  ovum,  therefore,  is  ex- 
pelled with  ruptured  membranes,  and  not  entire.  If  the  hemorrhage  be 
less  abundant  the  ovum  is  simply  detached,  and  this,  being  a  foreign 
body,  is  expelled  by  the  uterus,  either  entire,  or  with  ruptured  mem- 
branes, but  ruptured  here  from  another  cause.  We  insist  on  this  point, 
because  we  are  opposed  to  the  opinion  of  Gallard  and  of  Leblond,  who 
state  that  the  expelled  ovum  is,  in  the  early  months,  always  entire,  with 
membranes  intact,  and  who  believe  that  when  the  membranes  are  rup- 


MISCARRIAGE.  321 

turcd,  it  is  a  sign  of  criminal  abortion.  Miscarriage^  it  is  nndoubted,  has 
greater  chances  of  resulting  in  an  intact  ovum,  the  younger  this  is.  But, 
even  as  early  as  the  fifth  week,  the  ovum  may  be  expelled  with  torn  mem- 
branes, and  to  call  such  rupture  proof  of  criminal  attempts  is  in  opposi- 
tion alike  to  the  experience  of  scientific  and  practical  observation. 

That  which  characterizes,  in  particular,  miscarriage  at  this  period,  is 
the  initial  hemorrhage,  contractions  of  the  uterus  only  supervening  sec- 
ondarily. At  the  outset  there  exists  congestion,  then  hemorrhage,  and 
it  is  only  when  the  ovum  is  entirely  detached,  or  nearly  so,  that  contrac- 
tions appear  to  expel  it.  Now,  it  is  precisely  because  of  this  tardy  ap- 
pearance of  contractions  that  we  often  obtain  an  intact  ovum.  Since  the 
hemorrhage  affects  almost  complete  separation  of  the  ovum,  only  a  few 
uterine  contractions  are  necessary  to  complete  the  detachment,  and  the 
ovum  falls  on  the  cervix.  Then  it  only  has  to  overcome  the  resistance  of 
this  portion  of  the  uterus.  That  which  delays  the  completion  of  the 
miscarriage  is  not  the  ovum,  but  the  decidua.  As  for  the  ovum,  it  slowly 
insinuates  itself  in  the  cervix,  which  dilates  enough  for  its  passage,  but 
surrounded  as  it  is  by  clots,  it  passes  without  rupture. 

In  other  rare  instances,  the  contractions  of  the  uterus  are  the  initial 
phenomenon.  At  first  faint,  irregular,  these  contractions  approach  nearer 
one  another,  and  become  intense  enough  to  detach  the  ovum.  Here, 
the  hemorrhage  is  secondary. 

The  ovum  detaches  itself  slowly,  progressively,  little  by  little,  each  act 
being  preceded  by  contraction,  and  accompanied  by  hemorrhage,  which 
has  not  the  same  characters  as  at  first.  It  is  now  intermittent,  coincid- 
ing with  the  contractions,  and  the  more  intense  these  latter,  the  more 
abundant.  This  hemorrhage  only  ceases  with  the  expulsion  of  the  deci- 
dua. In  this  instance  the  ovum  is  living,  and  resists  destruction  as  far 
as  in  it  lies.  It  is  no  longer  a  foreign  body,  of  which  the  uterus  tries  to 
rid  itself  as  soon  as  possible;  it  is  a  living  being,  which,  engrafted  on  the 
maternal  organism,  requires,  for  its  separation,  heroic  and  persistent 
efforts.  Whence  the  longer  duration  of  the  miscarriage,  whence  the  alter- 
nation of  rest  and  pain,  the  intermittent  character  of  the  contractions 
which  is  typical  of  uterine  action,  in  particular  during  miscarriage.  It  is 
apparent,  therefore,  that  for  us  the  vitality  of  the  foetus  plays  an  impor- 
tant part  in  the  symptoms  of  miscarriage,  and  it  is  this  vitality  which  en- 
tails on  miscarriage  a  portion  of  its  gravity. 

In  case  the  ovum  is  dead,  a  number  of  days  may  pass  without  the 
woman  suffering  at  all  to  speak  of,  and  then  appears  a  gentle  flow  of  dark- 
ish blood,  which  may  last  six  or  eight  days,  in  the  absence  of  uterine  con- 
tractions. At  length  these  supervene,  a  digital  examination  is  made,  the 
cervix  is  found  more  or  less  dilated,  the  internal  os  open,  and  the  finger 
may  pass  in  and  touch  the  ovum.  Finally,  the  ovum  engages  in  the  cer- 
yix,  which  opens  still  further,  and  it  falls  into  the  vagina,  where  it  may 
Vol.  11—21. 


322  A    TREATISE    ON    OBSTETRICS. 

remain  some  time  before  expulsion.  The  amount  of  hemorrhage  accom- 
panjdng  the  process  may  be  slight,  there  may  be  none  at  all.  The  ovum, 
indeed,  having  died  some  time  before,  the  uterine  and  utero-placental 
circulation  have  become  deeply  modified  through  the  cessation  of  preg- 
nancy. Uterine  congestion  is,  thence,  relatively  slight,  and  therefore 
the  amount  of  blood  lost  is  also  slight. 

If  the  death  of  the  ovum  be  recent,  and  the  result  of  accident  or  trau- 
matism, if  miscarriage  follow  soon  on  the  death,  the  hemorrhage  precedes 
by  but  a  few  hours  the  onset  of  contractions;  frequently  even  they  ap- 
-peav  together,  and  the  hemorrhage,  if  the  act  of  miscarriage  be  a  trifle 
prolonged,  may  be  excessive  and  dangerous. 

If,  finally,  the  ovum  has  been  dead  a  long  time,  it  rests  quietly  in  the 
uterus  for  a  considerable  interval,  and  then,  of  a  sudden,  the  woman  loses 
blood,  violent  contractions  supervene,  and  in  a  few  hours,  at  times  almost 
at  once,  the  uterus  expels  this  foreign  body,  with  scarcely  any  premoni- 
tory symptoms.  This  variety  of  miscarriage  is  of  unusual  occurrence 
where  the  foetus  is  dead,  and  still  more  so  where  it  is  alive,  and  it  is  only 
as  the  result  of  violent  traumatism,  and  during  the  first  five  to  six  weeks 
of  pregnancy  that  we  see  it.     It  has  occurred  twice  in  our  experience. 

When  the  ovum  is  living,  and  the  process  of  miscarriage  is  prolonged, 
it  may  be  expelled  in  two  different  ways:  either  entire,  as  is  claimed  by 
Gallard  and  Leblond,  or  else  in  two  pieces,  so  to  speak,  as  ordinarily  hap- 
pens at  the  second  and  the  third  month.  Then  the  ovum  is  not  a  for- 
eign body  with  nothing  binding  it  to  the  uterus.  It  is  no  longer  hemor- 
rhage which  causes  it  to  separate,  but  it  is  the  contraction  of  the  uterus, 
and  the  ovum,  still  partially  attached  to  the  uterus,  is  incompletely  pushed 
towards  the  cervix  by  these  contractions.  Pushed  by  the  uterus  at  the 
time  of  contraction,  it  tends,  during  relaxation,  to  resume  its  normal 
place;  but  the  contraction  augments,  the  cervical  canal  opens,  the  ovum 
engages  within  it;  the  contraction  now  ceases,  and  the  ovum  lies  between 
two  forces,  the  cervix,  on  the  one  hand,  which  tends  to  retain  it,  the  body 
of  the  uterus,  on  the  other,  which  tends  to  pull  it  back  on  the  cessation 
of  contraction.  Whence  traction,  which,  if  the  adhesions  resist,  tends  to 
inevitably  rupture  the  ovum,  a  rupture  all  the  more  likely  the  greater  the 
vitality  of  the  ovum,  and  the  stronger  its  adhesions.  The  miscarriage  will, 
therefore,  occur  at  divided  periods;  the  foetus  will  issue  first,  the  remain- 
der of  the  ovum  later,  and  this  remainder  will  sometimes  be  expelled  only 
after  the  lapse  of  a  number  of  days.  It  is  in  these  instances  that  hemor- 
rhage may  be  profuse  and  serious.  For  apart  from  its  intensity,  the 
woman  is  exposed  to  a  renewal  as  long  as  the  placenta  remains  in  the 
uterus.  The  uterine  contractions  are  irregular,  intermittent,  appearing 
for  a  while,  and  then  disappearing,  and  this  very  prolongation  of  labor  is 
of  grave  import  for  the  welfare  of  the  woman.     We  will  see  further  on 


MISCARRIAGE.  323 

that  there  is  another  danger,  depending  on  retention  of  the  placenta,  and 
on  the  alterations  it  may  suffer. 

The  prolongation  of  labor,  in  these  cases,  depends,  on  the  one  hand, 
on  the  weakness  of  the  uterine  contractions,  and,  on  the  other,  on  the 
resistance  of  the  cervix  and  the  adhesions  of  the  decidua. 

Weakness  of  contraction  is  to  be  expected  at  this  period.  The  uterus 
has  by  no  means  attained  the  muscular  development  it  will  later;  the 
muscular  layer  is  only  in  process  of  formation,  and  contractility,  hence, 
can  be  present  only  incompletely.  Again,  the  cervix,  at  two  months,  has 
changed  simply  through  a  little  softening  at  the  tip.  It  has  still  its  nor- 
mal length.  At  labor  at  term,  the  cervix,  which  has  been  softening 
throughout  pregnancy,  first  disappears,  then  dilates,  being  represented 
simply  by  a  ring,  the  result  of  the  disappearance  of  the  external  os,  and  the 
opening  of  the  internal.  In  case  of  miscarriage,  however,  the  cervix 
neither  softens,  nor  dilates,  but  only  opens  sufficiently  to  allow  of  the  pas- 
sage of  the  ovum.  It  retains  its  entire  length;  the  two  orifices  remain  at 
the  same  distance,  one  from  another;  the  ovum  is  obliged  to  pass  through 
a  canal,  the  more  rigid  the  less  advanced  the  pregnancy.  Whence,  there- 
fore, an  additional  resisting  force  it  has  to  overcome,  and  whence,  also, 
the  likelihood  of  rupture,  the  greater  the  more  intense  the  uterine  con- 
tractions, the  rigidity  o£  the  cervix,  and  the  length  of  the  labor.  Miscar- 
riage may  last  for  days,  and  even  for  weeks.  The  process  is  started  by 
the  uterine  contractions,  the  ovum  tends  to  become  detached,  but  un- 
equally; pushed  against  the  cervix,  it  engages  in  the  canal,  and  it  tears. 
What  happens  then  ?  The  foetus,  which  is  so  small  and  weak,  passes 
out  first,  and  easily.  The  cord,  scarcely  formed,  breaks,  and  the  ovum 
may  be  lost  in  the  discharges.  The  true  miscarriage,  however,  has  not 
occurred;  the  membranes  and  the  placenta  must  still  detach  themselves, 
and  it  is  only  at  the  end  of  a  few  days  that  these  are  shed,  and  the  mis- 
carriage is  ended.  These,  then,  are  the  two  stages  at  this  period  of  ges- 
tation. The  cervix  closes  after  the  escape  of  the  fcetus.  A  second  labor 
is  needed  for  the  expulsion  of  the  remainder  of  the  ovum. 

From  two  and  a  half  to  three  and  a  half  months  the  conditions  are  still 
more  different.  The  placenta  has  been  definitively  formed,  it  is  relatively 
larger  than  the  fcetus,  it  is  attached  more  firmly  to  the  uterus.  In  case 
of  accident  or  of  hemorrhage,  the  ovum  will  no  longer  separate  entire, 
but  only  by  portions  from  the  uterus.  Therefore  miscarriage  in  two 
stages  becomes  the  rule,  and  in  one  the  exception.  The  uterus  is  far  from 
having  acquired  its  definitive  structure,  the  muscular  fibres  are  still  in  a 
rudimentary  condition,  and  hence,  the  uterine  contractions  are  too  feeble 
to  detach  the  placenta.  Whence  the  infinite  duration  of  the  process,  at 
times.  Furthermore,  there  is  marked  disproportion  between  the  dilata- 
tion of  the  cervical  canal  and  the  body  which  has  to  pass  through  it.  The 
cervix,  indeed,  still  neither  dilates  nor  retracts;  whence,  again,  the  likeli- 


324  A   TEEATISE    ON    OBSTETRICS. 

hood  of  rupture  of  the  membranes.  Under  the  influence  of  contractions, 
the  internal  os  opens,  the  ovum  enters  the  canal,  and  remains  there  for  a 
number  of  days.  Then,  at  a  given  time,  as  a  result  of  a  contraction,  or 
of  some  effort  on  the  part  of  the  woman,  the  ovum  ruptures,  and  the  em- 
bryo is  expelled  through  the  cervix,  and  often  breaks  the  cord;  if  not, 
the  embryo  remains  attached  to  the  cord  until  traction,  or  effort  of  the 
woman,  breaks  it.  The  placenta  stays  in  the  uterus,  and,  whether  sepa- 
rated or  not,  a  new  labor  is  necessary  for  its  expulsion.  The  cervix  closes, 
and  new  contractions  are  needed  to  re-open  it  for  the  passage  of  the  pla- 
centa. If  this  organ  has  entirely  separated,  hemorrhage  is  ordinarily  not 
abundant,  except  at  the  time  of  expulsion;  if  separation  be  incomplete, 
the  hemorrhage  lasts  until  detachment  has  occurred.  In  any  case,  no 
effort  should  be  made  to  remove  it,  before  its  engagement  in  the  cervix, 
othern^ise,  there  is  risk  of  tearing  it,  and  of  leaving  portions  in  the  uterus, 
and  still  another  labor  will  be  necessary  for  the  expulsion  of  the  remnants; 
and  if  this  new  labor  should  not  supervene,  the  placental  shreds  may 
putrefy,  and,  as  we  will  see^  entail  grave  complications. 

The  above  is  not  all.  There  is  another  element  which  we  must  remem- 
ber, and  this  is  the  decidual  membrane.  In  labor  at  term  this  membrane 
is  really  decidual,  because  it  has  lost  its  vitality;  but  in  miscarriage,  it  is 
still  living,  and  adheres  strongly  to  the  uterus;  and  instances  are  not 
rare  where  miscarriage  is  divisible  into  three  stages,  one  for  the  foetus, 
one  for  the  placenta,  one  for  the  uterine  mucous  membrane. 

Very  infrequently,  in  our  opinion,  the  ovum  is  expelled  entire  at  this 
period  of  gestation,  and  then  the  foetus  is  dead. 

From  three  and  a  half  to  the  seventh  month,  miscarriage  approaches, 
progressively,  nearer  in  character  to  labor  at  term.  Two  stages  are  the 
rule.  The  muscular  fibre  of  the  uterus  is  more  developed,  the  uterine 
mucous  membrane  is  detached  the  more  readily,  and  while  considerable 
time  elapses  between  the  expulsion  of  the  foetus  and  that  of  the  placenta, 
this  interval  is  relatively  less.  It  is  exceptional  to  see  the  expulsion  of  the 
placenta  delayed  beyond  twelve  to  twenty-four  hours.  The  nearer  to  the 
seventh  month  the  less  profuse  the  hemorrhage;  but  even  up  to  the  fifth 
month,  it  may  be  very  considerable. 

Such  are,  in  outline,  the  phenomena  of  miscarriage  at  various  stages 
of  gestation.  We  now  consider,  in  detail,  each  of  these  phenomena,  the 
hemorrhage,  the  uterine  contractions,  the  modifications  of  the  cervix. 

Uterine  Hemorrhage. — This  is  intimately  connected  with  miscarriage, 
and  if  every  hemorrhage  does  not  determine  the  process,  we  may,  never- 
theless, say  that  there  can  occur  no  miscarriage  without  hemorrhage. 
The  very  structure  of  the  ovum,  even  during  the  first  months,  necessi- 
tates this.  Immediately  at  conception,  the  ovum  becomes  surrounded  by 
vascular  villi,  its  detachment  is,  therefore,  necessarily  accompanied  by 
hemorrhage.     Again  in  case  of  premature  detachment  of  the  ovum,  the 


MISCARRIAGE.  325 

separation  occurs  but  slowly,  and  here  is  another  source  of  bleeding. 
'J'lie  appearance  of  hemorrliage,  therefore,  in  the  early  months  of  preg- 
nancy, should  always  awaken  the  anxiety  of  the  accoucheur.  lu  the  vast 
majority  of  cases,  it  is  an  indication  of  impending  miscarriage. 

[It  is  well  to  recall  further  causes  of  hemorrhage,  slight  in  amount  usu- 
ally, during  the  early  months  of  pregnancy.  Up  to  the  sixth  or  eighth 
week  it  is  still  allowable  to  think  of  a  return  of  the  menses.  At  a  later 
period,  although  there  are  a  few  undoubted  instances  on  record,  men- 
struation can  hardly  occur  without  imperilling  the  ovum.  Frequent 
causes  of  hemorrhage  are,  slight  separation  of  the  ovum,  the  result,  not 
infrequently  of  violent  or  often  repeated  coitus,  erosions  of  the  external 
OS,  cervical  polypi  or  tumors,  carcinoma  of  the  cervix,  lacerations  of  this 
organ.  The  point  we  desire  to  insist  upon  is  that  in  every  instance  where 
a  gravid  woman  complains  of  hemorrhage,  both  a  digital  and  specular 
examination  should  be  made  to  determine  if  one  or  another  of  the  above 
causes  be  not  at  the  bottom  of  it,  instead  of  impending  miscarriage. — Ed.] 

This  hemorrhage  is  sometimes  preceded  by  signs  of  uterine  congestion, 
sometimes  is  sudden  in  appearance.  It  may  be  internal,  external,  or 
mixed.  "When  the  hemnn-hage  is  internal,  it  maybe  limited  to  the 
membranes,  to  certain  portions  of  the  placenta,  constituting  what  has 
been  called  placental  apoplexy.  It  may  then,  if  slight,  not  determine 
quickly  either  labor,  or  the  expulsion  of  the  foetus,  or  its  death.  One  or 
another  of  these  result  only  after  the  repetition  of  such  hemorrhage.  In 
other  instances,  it  may  be  profuse,  and  may  spread  throughout  the  entire 
placenta,  the  whole  ovum  separating  without  the  appearance  of  the  least 
blood  externally/'     (Jacquemier.) 

The  precursory  signs  of  miscarriage,  it  is  understood,  are  more  or  less 
intense,  according  to  the  amount  of  separation  of  the  ovum,  which  fol- 
lows on  the  hemorrhage.  The  uterus,  distended  by  blood  and  clots,'  be- 
gins to  contract,  and  this  contraction  becoming  more  frequent,  the  cervix 
opens,  and  the  clots,  with  a  little  fluid  blood,  pass  out.  The  hemor- 
rhage has  become  external. 

When  the  hemorrhage  is  external,  it  may  begin  by  a  simple  trickling 
of  a  reddish  fluid,  only  becoming  later  hemorrhagic  in  character,  or  else 
announce  itself  at  once  by  the  appearance  of  clots  and  blood.  Some- 
times the  blood  is  black,  followed  only  later  by  red»  The  duration  of  the 
flow  is  variable.  It  may  begin  with  the  miscarriage  and  persist  continu- 
ously to  the  end;  again  it  may  appear  only  with  the  contractions.  At 
times  it  ceases  not  to  recur  until  the  expulsory  act,  and  then  profusely. 
The  amount  lost  is  very  variable,  from  a  few  drops  on.  It  comes,  we 
believe,  from  both  the  arteries  and  the  veins,  and  as  a  result  of  the  rup- 
ture of  the  mucous  membrane  and  detachments  of  the  placenta,  which 
leave  open  the  uterine  sinuses.  The  blood,  hence,  is  rather  venous  than 
arterial. 


326  A   TREATISE    ON    OBSTETRICS. 

Uterine  Co7itractions. — Like  those  whicli  occur  at  term,  these  are  pain- 
ful, although  less  intense,  and  they  differ  in  regularity  and  in  rhythm. 
Instead  of  pains  progressively  increasing  in  duration  and  in  intensity, 
and  which  are  separated  by  intervals  less  and  less  long,  the  contractions 
of  miscarriage  recur  frequently  at  very  long  intervals  only,  during  seve- 
ral days,  until  they  finally  become  established,  and  expel  the  foetus. 

Changes  in  the  Cervix. — These  are  not  at  all  comparable  to  those  vi^hich 
have  occurred  at  term.  Jacquemier  thus  describes  these  changes:  under 
the  influence  of  the  uterine  contractions,  there  occur  alterations  in  the 
cervix,  which  are  the  first  indices  of  effective  labor.  These  contractions 
are,  for  some  time,  obscure,  irregular,  as  though  continuous,  with  mo- 
mentary exacerbations.  The  cervix  is  shortening  and  softening,  the  ora 
are  opening,  first  the  external,  and  then  the  internal,  the  vagina  is  re- 
laxing, and  is  covered  by  a  thick,  abundant  mucus.  The  body  of  the 
uterus  sinks  into  the  pelvis.  Only  after  the  above  changes  have  occurred, 
do  the  contractions  become  regular,  and  truly  intermittent.  This  period 
of  labor  may  last  a  number  of  days.  Once  the  cervix  softened  and  re- 
laxed, dilatation  supervenes  quickly  enough,  if  the  contractions  are  good. 
This  dilatation  is  accomplished  as  follows.  As  the  cervix  softens  it 
shortens — [Does  it  not  rather  seem  to  shorten,  from  the  very  fact  of  the 
softening?  This  matter  is  in  dispute. — Ed.] — and  the  external  and  inter- 
nal OS  approach  one  another.  The  internal  os  insensibly  opens  more  and 
more,  and  the  contractions  act  on  the  external  os,  the  border  of  which 
becomes  thin,  and  cutting,  as  dilatation  progresses.  The  ovum  presents 
at  this  orifice,  and  is  projected  out  by  a  pain.  These  expulsory  pains  not 
only  dilate  the  cervix,  and  drive  out  the  ovum,  but  they  cause  rupture  of 
its  adhesions  to  the  uterus.  Whence  the  premature  hemorrhages  which 
ordinarily  accompany  miscarriage,  and  which,  in  labor  at  term,  or  in  ad- 
vanced stages  of  pregnancy,  are  only  seen  after  the  expulsion  of  the  foetus. 
As  soon  as  the  entire  ovum  has  been  expelled  into  the  vagina,  the  pains 
and  the  hemorrhage  cease. 

The  phenomena  which  follow  the  regular  expulsion  of  the  ovum  are 
very  similar  to  those  of  labor  at  term,  but  less  accentuated  the  earlier  the 
period  of  gestation. 

The  LocUal  Discharge. — This  is  scarcely  noticeable  after  very  early  mis- 
carriage, and  more  and  more  marked  thereafter,  especially  when  the  de- 
cidual mucous  membrane  separates  brtt  slowly.  The  sero-sanguineous 
discharge  then  lasts  a  long  time,  and  in  the  uterine  and  vaginal  excretions 
are  found  blackish  debris,  often  very  fetid.  Truly,  as  G-arimond  has  well 
said,  we  are  dealing  not  with  the  lochia,  but  with  a  discharge  caused  by 
the  fact  that  the  miscarriage  is  incomplete.  It  ceases  with  the  expulsion 
of  the  last  shred. 

The  Lacteal  Secretion. — This  is  present,  as  we  have  already  stated,  before 
miscarriage,  in  cases  where  the  f cetus  dies,  but  it  ordinarily  recurs  after 


MISCARRIAGE.  327 

the  expulsion  of  tlie  ovnm.  Usually  this  is  the  case  in  multiparge,  and 
after  the  third  month.  Joulin  has  related  a  case  where  milk  was  secreted 
six  weeks  after  impregnation.- 

Finallj^,  involution  takes  place  more  rapidly  than  after  labor  at  term,  at 
least  as  regards  the  cervix,  which  closes  much  more  quickly,  and  also  re- 
gains its  length  and  consistency  sooner.  The  same  does  not  apply  to  the 
body,  and  it  is  not  unusual,  after  miscarriage,  to  find  the  body  of  the 
uterus  remain  larger  than  the  normal;  and  in  case  of  frequently  repeated 
miscarriages,  this  incomplete  involution  merges  into  hyperplasia,  the 
more  so,  indeed,  because  the  precautions  taken  after  miscarriage,  parti- 
cularly in  the  early  months,  are  far  less  than  after  term. 

After-pains  do  not  follow  miscarriages  in  the  first  months;  usually  they 
are  not  present  till  after  the  fifth  in  multipara.  When  they  do  exist,  it 
is  usually  proof  that  the  miscarriage  was  incomplete,  and  that  shreds  of 
the  decidua  are  still  in  the  uterus. 

Diagnosis. — In  the  diagnosis  of  miscarriage  there  are  included  a  num- 
ber of  questions:  1.  Is  the  woman  pregnant?  2.  Pregnancy  assured,  are 
the  symptoms  those  of  pure  uterine  congestion  or  of  beginning  miscar- 
riage? 3.  Is  miscarriage  inevitable  ?  4.  Is  the  miscarriage  complete,  or 
are  there  still  in  the  uterus  shreds  of  membrane,  of  placenta,  or  of  deci- 
dua? 

Is  the  woman  pregnant  ?  If  the  diagnosis  of  pregnancy  is  easy,  after 
the  fourth  month,  Avhen  the  foetal  heart,  and  the  active  movements,  of 
the  fcetus  are  appreciable,  it  is  far  from  being  so  in  the  earlier  months 
when  all  we  possess  are  the  probable  signs.  There  is  nevertheless  one 
sign  which  may  be  of  the  highest  importance,  and  this  is  the  suppression 
of  the  menses.  If  the  woman  was  regular  up  to  the  time  of  suppression, 
if  this  latter  has  occurred  Avithout  morbid  cause,  if  the  rational  signs  of 
pregnancy  are  present,  if,  in  case  of  a  nullipara,  the  mammary  areola,  and 
Montgomery's  follicles  are  present,  then  the  chances  are  great  that  we  are 
dealing  with  pregnancy.  If,  under  such  circumstances,  persistent  lumbo- 
hypogastric  pains  appear,  with  momentary  exacerbations;  if,  at  the  same 
time,  there  appear  an  abundant  bloody  discharge,  persisting,  and  mixed 
with  clots;  if  at  the  same  time,  the  cervix  is  softened,  and  the  external 
OS  is  open,  we  are  nearly  certain  that  we  are  in  the  presence  of  a  miscar- 
riage. One  point  only  is  in  doubt,  if  we  have  not  been  present  from  the 
start,  and  have  not  seen  the  discharge  and  clots, — this  is  if  the  miscar- 
riage is  complete  or  not. 

When,  on  the  other  hand,  the  woman  is  naturally  irregular,  the  diag- 
nosis is  far  more  difficult.  The  suppression  of  the  menses  loses  its  value 
in  diagnosis.  It  is  not  exceptional,  indeed,  to  meet  women  who  men- 
struate only  every  tAvo  to  three  months,  in  whom  the  breasts  swell,  the 
abdomen  enlarges,  and  Avho  ]oi'esent  the  signs  of  pregnancy  in  its  begin- 
ning, and  yet  are  not  so. 


328  A    TREATISE    ON    OBSTETEICS. 

According  to  Madame  Lacliapelle,  tlie  hemorrhage  precedes  and  accom- 
panies the  pains,  and  increases  with  the  intensity  of  the  pains,  and  is  al- 
ways attended  by  clots,  in  case  of  miscarriage.  In  case  of  dysmenorrhoea, 
on  the  other  hand,  uterine  contractions  always  precede  the  hemorrhage, 
and  diminish  as  the  hemorrhage  increases.  Further,  clots  are  always  less 
abundant  than  in  case  of  miscarriage.  In  miscarriage  the  os  is  open,  and 
the  cervix  modified  in  consistency,  while  it  remains  closed  and  is  not 
softened  in  dysmenorrhoea.  Clots  coming  from  the  empty  uterus  are  tri- 
angular, while  in  miscarriage  they  have  no  special  shape.  All  these  signs 
are  more  than  hypothetical,  and  hence  are  of  little  value. 

Still  further,  there  are  certain  women  who,  during  the  first  three  months 
of  pregnancy,  suffer  from  slight'  hemorrhages  which  do  not  seem  to  have 
a  tendency  to  provoke  miscarriage.  Such  women  may  not  know  that 
they  are  jDregnant,  believing  themselves  to  be  menstruating.  These  slight 
hemorrhages  differ,  liowever,  from  the  menses,  in  that  they  do  not  cor- 
respond to  the  menstrual  epoch,  either  in  time,  quantity,  or  duration. 

We  see,  then,  that  there  are  many  sources  of  ea'ror,  and  it  is  only  by 
obtaining  all  possible  information,  and  by  examining  the  discharges  and 
the  clots  that  we  can  reach  a  nearly  certain  diagnosis. 

[The  decision  as  to  whether  the  woman  is  pregnant  or  not,  it  seems  to 
us,  may  almost  infallibly  be  reached  by  a  sign  not  mentioned  by  the 
author,  and  this  is  Ilegar's  sign  of  early  pregnancy,  which  we  have  de- 
scribed in  the  first  volume,  under  the  Diagnosis  of  Pregnancy. — Ed.] 

The  woman  is  pregnant,  then,  but  are  the  symptoms  purely  those  of 
simple  uterine  congestion,  or  is  miscarriage  imminent? 

In  the  majority  of  instances,  as  Cazea,ux  justly  says,  "  We  cannofc  tell 
whether,  even  when  pains  have  ceased,  if  the  congestion  has  been  relieved 
before  vascular  rupture,  and  hemorrhage  between  the  placenta  and  the 
uterus  have  killed  the  foetus.  Even  though  the  foetus  be  still  alive,  we 
know  nothing  about  the  extent  of  placental  separation.  Often,  indeed, 
the  foetus,  deprived  of  a  greater  part  of  its  respiratory  means,  is  placed 
in  the  same  condition  as  an  adult  in  whom  a  greater  part  of  the  lungs 
has  been  destroyed;  there  remains  only  insufficient  respiration  and 
nutrition,  it  dies  little  by  little,  and  it  is  only  after  the  lapse  of  eight  to 
fifteen  days,  often  at  the  next  menstrual  epoch,  that  it  finally  succumbs. '^ 
Jacquemier,  further,  has  insisted  that  the  first  placental  apoplexy  pre- 
disposes to  others,  since  it  interferes  Avith  the  development  of  the  placenta. 

Miscar^nage  has  Co7mnenced. — Is  it  inevitable,  or  can  it  be  caused  to 
cease  ?  Generally  it  may  be  said  that  as  long  as  the  fostus  is  not  dead, 
miscarriage  may  be  prevented.  But,  if  at  the  fourth  month,  we  possess 
certain  signs  of  the  life  or  the  death  of  the  foetus,  the  same  does  not  hold 
true  before  this  period,  and,  as  we  have  seen,  it  is  during  the  first  three 
months  that  miscarriage  most  frequently  occurs.  The  foetus  once  dead, 
the  miscarriage  will  necessarily  occur  sooner  or  later.    One  sign  alone,  may 


MISCARRIAGE.  329 

"be  of  value,  and  this  is  the  cessation  of  all  the  rational  signs  of  pregnancj^- 
but  there  are  many  women  in  wliom  these  signs  are  so  little  marked  as 
not  to  be  noticed. 

However  intense  the  joains,  however  in  character  like  uterine  contrac- 
tions, however  much  the  profaseness  of  the  hemorrhage,  or  however 
marked  the  change^  in  the  cervix,  we  are  yet  not  justified  in  considering 
the  miscarriage  inevitable  if  the  ovum  be  intact,  and  the  membranes  not 
ruptured.  In  certain  exceptional  cases  all  these  signs  have  disappeared, 
and  the  pregnancy  has  continued. 

There  are  other  instances  again  where  the  diagnosis  is  still  more  diffi- 
cult. For  instance:  The  woman  had  been  certainly  jDregnant,  she  has 
passed  through,  apparently,  a  miscarriage,  having  lost  much  blood,  and 
suffered  greatly  from  the  contractions  of  the  uterus.  Clots  have  been 
passed  and  with  them  a  body,  which  a  midwife  or  a  physician  has  ex- 
amined, and  pronounced  an  ovum,  and  furthermore  it  is  stated  that  the 
miscarriage  is  complete.  This  body  has  been  thrown  away,  and  the  ac- 
coucheur, hence,  cannot  examine  it.  The  bloody  discharge  continues, 
the  woman  does  not  regain  her  strength.  Now  has  she  really  miscar- 
ried, and  did  the  body  really  constitute  the  ovum  ?  Is  the  miscarriage, 
if  one  has  occurred,  complete  or  incomplete  ?  Here  the  diagnosis  is  diffi- 
cult, and  often  cannot  at  once  be  made.  If  the  ovum  has  really  been 
expelled,  the  hemorrhage  will  shortly  cease,  the  cervix  and  the  body  of 
the  uterus  will  return  to  the  normal.  If  the  miscarriage  be  incomplete, 
at  the  end  of  a  certain  interval  the  hemorrhage  and  the  uterine  contrac- 
tions will  recur,  and  the  remnant  be  expelled,  or  else  some  pathological 
factor  will  supervene  pointing  to  the  retention  of  ovular  remnants  in  the 
cavity  of  the  uterus.  ISTot  infrequently  a  portion  of  the  placenta  remains 
behind,  the  woman  will  bleed  irregularly,  and  have  occasional  contrac- 
tions until  it  has  been  shed.  Sometimes  this  placental  remnant  under- 
goes complete  changes  in  the  uterus,  and  these  are  two  in  number:  either 
this  remnant  becomes  converted  into  a  fibrinous  polyp,  (Fig.  28),  as  has 
been  noted  by  Kiwisch,  Virchow,  Scanzoni,  Sallinger,  Frankel,  Dun- 
can, etc. ;  or  else,  more  frequently,  the  remnant  empties  itself  of  the  blood 
which  it  contained,  becomes  hard,  takes  the  shape  of  the  uterine  cavity, 
and  is  transformed  into  what  has  been  called  placental  polyp.  (Braiin, 
Schroeder,  Valenta,  Frankenhauser,  Martin,  etc.) 

In  other  instances  the  diagnosis  is  still  more  difficult;  where  a  placen- 
tal tuft,  or  remnant  of  membrane  or  of  decidua,  remains  in  the  uterus, 
and  undergoes  change.  Here,  instead  of  abruptly  ceasing,  the  discharge 
persists,  being  black  in  color,  and  composed  of  detritus,  and  further — a 
very  characteristic  phenomenon — is  intensely  fetid.  At  the  same  time 
the  woman's  health  is  compromised.  She  suffers  from  chilly  sensations, 
and  has  fever,  effects  which  we  will  study  when  we  speak  of  puerperal 
complications. 


330 


A   TREATISE    ON   OBSTETRICS. 


Prognosis, — For  the  foetus^  of  course,  it  means  death,  since  it  is  ex- 
pelled before  it  is  suitable  for  extra-uterine  life.  Eor  the  mother,  it  is 
grave,  for,  even  if  life  is  rarely  compromised,  health  very  frequently  is; 
everything  depends,  however,  on  the  progress  of  the  miscarriage,  and  on 
the  period  of  gestation  at  which  it  occurs.  The  prognosis  is  the  graver, 
of  course,  where  pregnancy  is  advanced,  and  the  fcetus  and  the  foetal  an- 
nexes are  shed  separately,  because  to  the  dangers  of  miscarriage  are  added 
those  of  retained  placenta,  and  its  consecutive  alterations.  G-enerally, 
in  a  word,  the  prognosis  is  most  unfavorable  in  cases  where  the  miscar- 
riage is  the  result  of  criminal  manipulations  or  of  disease  of  the  mother. 
If  we  compare  the  process  of  miscarriage  with  confinement  at  term,  aside 
from  puerperal  fever  which  is  more  common  after  the  latter,  the  former 


Fig.  28.— Fibrinous  Placental  Polypi.— a,  Fibrinous  polyp, 


al  site,  c,  Uterine  cavity. 


predisposes  to  metritis,  to  displacements.  The  complications  of  miscar- 
riage, above  all  of  note,  are: '  profuse  hemorrhages  and  retention  of  a 
portion  of  the  ovum.  Garimond  insists  on  a  third,  faulty  position  of  the 
foetus.  In  our  opinion  this  does  not  constitute  a  serious  complication, 
for  up  to  the  fourth  month  the  foetus  is  too  small  to  give  rise  to  trouble, 
and  at  five  and  six  months,  the  foetus  is  so  soft  and  compressible  that  it 
readily  passes  whatever  the  presentation.  What  really  constitutes  the 
gravity  in  these  cases  is  the  hemorrhage  which  accompanies  the  prolon- 
gation of  labor,  and  which  may  be  so  profuse  as  to  become  very  disquieting. 
Although  vertex  presentations  are  the  rule  in  labor  before  term,  it  is 
still  true  that  the  frequency  of  pelvic  and  of  transverse  presentations  m- 


JMISCARKIAGE.  661. 

creases  considerably  the  further  from  term  the  pregnancy  is  interrupted. 
Tf  we  conjoin  the  statistics  of  Veit  and  of  Ilugenberger,  we  find  that  of 
1517  children  born  at  the  seventh,  eighth  and  ninth  month,  76.1  per 
cent,  were  cephalic  presentations;  19.9  per  cent,  pelvic;  3.7  per  cent, 
transverse;  while  of  355  children  born  at  the  fifth  to  sixth  month,  only 
54.6  per  cent,  were  cephalic  presentations;  40.2  per  cent,  pelvic,  and  5 
per  cent,  transverse.  In  these  figures,  however,  are  included  macerated 
foetuses,  where  the  presentation  alters  from  change  in  the  centre  of  grav- 
it3^  But  even  if  these  cases  be  left  out,  the  law  remains  an  exact  one. 
For,  according  to  Veit,  of  379  children  (eighth  to  ninth  month),  there 
were  84.7  per  cent,  cephalic,  13.7  per  cent,  pelvic,  and  1.6  per  cent, 
transverse  presentations;  of  43  children  (fifth  to  sixth  month),  63.8  per 
cent,  were  cephalic,  27.9  per  cent,  pelvic,  and  9.3  per  cent,  transverse. 

Complications. 

I.  Hemorrhage. — This  always  accompanies  miscarriage  in  the  early 
months.  Generally  intermittent,  it  is  usually  well  borne  by  the  woman; 
at  times,  however,  it  may  be  because  of  difficulty  in  the  separation  of  the 
decidua,  it  may  be  because  of  special  hemorrhagic  tendency,  or  of  a  natu- 
ral atony  of  the  genital  system;  it  becomes  very  profuse,  and  is  accom- 
panied by  syncope,  small  pulse,  cold  extremities,  in  a  word,  by  all  the 
symptoms  indicative  of  great  loss  of  blood.  It  is  particularly  at  from  two 
months  to  three  and  a  half  that  such  hemorrhages  are  noted,  and  when- 
ever miscarriage  occurs  in  two  stages.  The  reason  is  that,  in  such  cases, 
the  ovum  separates  but  slowly,  and  that  the  cervix  closing  np  after  the 
expulsion  of  the  embryo,  a  second  labor  is  necessary  for  the  shedding  of 
the  remainder  of  the  ovum.  Now,  we  have  seen,  that  this  second  labor 
may  last  a  number  of  days  or  weeks,  and  all  this  time  the  woman  loses 
blood,  often  profusely.  The  hemorrhage,  therefore,  is  grave,  not  only 
from  its  profuseness,  but  from  its  duration.  If  it  does  not  compromise 
the  life  of  the  woman,  it  does  her  health,  leaving  her  in  a  state  of  anemia, 
from  which  she  may  recover  but  sloAvly. 

II.  Retention  of  the  Ovum,  and  of  the  Placenta. — "From  the  study  of 
the  means  of  union  of  the  placenta  to  the  uterus,  Meyer  states  that  this 
union,  very  intimate  in  the  early  months  of  pregnancy,  becomes  less  so 
as  pregnancy  advances,  through  the  retrograde  processes  which  occur  in 
the  decidua  serotina  and  in  the  utero-placental  vessels;  and  that  retention 
of  the  placenta  depends,  on  the  one  hand,  on  the  feebleness  and  irregu- 
larity of  the  uterine  contractions,  and,  on  the  other,  on  the  firm  adhesions 
of  the  placenta  to  the  uterine  wall  in  case  of  miscarriage,  whether  these 
adhesions  are  normal  or  due  to  a  pathological  process.  In  the  early  stages 
of  pregnancy,  the  placenta  is  divisible  into  two  portions,  the  maternal 
and  the  foetal.  The  bond  of  union  between  these  is  feeble,  and  the  foetal 
villi  are  easily  separable  from  the  maternal  portion  of  the  placenta.     Still, 


332  A   TREATISE   ON   OBSTETEICS. 

the  uterine  mucous  membrane,  and,  in  particular,  that  between  the  uterus 
and  placenta,  adheres  firmly  to  the  uterine  wall,  whence  one  of  the  rea- 
sons why  it  is  often  retained  in  the  uterus  after  miscarriage.  Up  to  the 
end  of  the  third  month,  this  mucous  membrane  separates  slowly  and  with 
difficulty.  Afterwards,  the  changes  which  it  undergoes  renders  its  shed- 
ding easier,  and,  consequently,  its  retention  unusual.  Up  to  the  third 
month,  hence,  we  observe  either  the  retention  of  the  entire  placenta,  or, 
oftener,  of  the  serotina  and  the  adjoining  parts  of  the  foetal  placenta. 
This  retention  is  due  to:  1.  The  firm  adhesion  of  the  maternal  placenta 
to  the  uterine  wall.  2.  The  ease  with  whicii  the  foetal  portion  separates 
from  the  maternal.  3.  The  feeble  development  of  the  muscular  tissue  of 
the  body  of  the  uterus.  4.  The  slight  dilatation  of  the  cervix.  5.  The 
pathological  processes  which  are  often  the  cause  of  miscarriage,  and  which 
may  exist  in  the  uterus,  in  the  foetal  annexes,  in  the  organs  neighboring 
on  the  uterus. 

When  the  miscarriage  is  not  determined  by  premature  involution  of  the 
decidua,  or  by  joathological  processes  which  necessitate  the  complete  sep- 
aration of  the  decidua,  the  expulsion  of  the  product  of  conception  is 
usually  incomplete.  Either  the  entire  placenta,  or  shreds  of  the  decidua, 
or  of  the  serotina,  remain  in  the  uterus.  Now  the  expulsion  of  these 
remnants  may  require  an  interval  of  many  weeks,  and  even  months. '^ 

The  placenta  retained  in  the  uterus  may  undergo  cystic  degeneration,, 
as  has  been  pointed  out  by  Meckel,  Scanzoni,  Muller,  Virchow,  and 
others. 

"We  would  further  mention  as  causes  of  placental  retention,  the  diseases 
of  this  placenta,  and  endometritis. 

These  placentas,  thus  retained  for  a  longer  or  shorter  time  in  ths' 
uterus,  may:  a.  Be  expelled  not  altered,  not  putrid,  b.  Altered  and 
putrid,  c.  With  symptoms  of  septic  fever,  d.  Without  such  symptoms. 
e.  Be  absorbed,    /.  Eemain  indefinitely  in  the  uterus. 

a.  Retarded  JExpuIsion  without  Alteration. — When  the  placental  adhe- 
sions are  not  firm,  and  the  probable  cause  of  retention  is  functional  trouble 
of  the  uterus,  or  slight  mechanical  obstacles,  then  the  efforts  of  nature 
may  suffice  for  its  elimination,  and  this  occurs  shortly  through  uterine' 
contractions  alone.  It  is  about  the  tenth  to  the  fifteenth  day  that  the 
placenta  begins  to  separate,  and  that  hemorrhage  reappears;  but  the  in- 
terval may  be  months,  and  the  only  sign  accompanying  the  shedding  is 
sub-involution,  and  one  of  its  consequences,  hemorrhage.  The  placenta 
may  be  slightly  degenerated,  but  this  is  not  always  so;  it  is  especially  thfr 
case  when  we  are  dealing  with  shreds  of  the  ovum.  Baudelocque  has 
noted  such  retention  for  many  months.  Cazeaux  says :  ' '  When  we  examine 
these  placentas  they  are  not  altered,  and  have  no  odor,  and  they  may  be 
as  fresh,  even  after  weeks,  as  though  extracted  immediately  after  miscar- 
riage.    The  integrity  of  the  vascular  connections  has  given  them  lease  of 


MISCAREIAGE.  333 

life,  and  explains  the  innocuousness  of  this  prolonged  retention.  Schcller 
lias  noted  retention  for  eleven  weeks;  Metz  for  two  and  a  half  months; 
Frost,  103  days;  Plasse,  15  weeks,  and  Pieichmann,  13  weeks. 

Unfortunately,  the  aboA'^e  is  not  always  the  case,  and  hemorrhage  may 
be  so  profuse  as  to  compromise  life.  Heckiug  cites  a  case  where  the  pla- 
cental remnant  was  passed  only  at  the  end  of  four  and  a  half  months. 
During  this  entire  period  the  woman  had  profuse  hemorrhages. 

During  retention,  the  uterus  retains  its  increased  size.  Sometimes 
the  vaginal  portion  of  the  cervix  is  shortened,  the  external  os  open, 
the  lips  softened  and  swollen,  the  internal  os  patent.  The  lower 
segment  of  the  uterus  is  full  and  distended,  the  boundary  between 
cervix  and  body  is  not  marked.  Again,  the  cervix  is  closed,  and  has 
resumed  its  shape;  and  again,  the  internal  os  alone  is  closed.  The 
functional  troubles  of  the  uterus  are  manifested  by  pains,  occurring, 
usually,  when  the  placenta  partially  detaches  itself.  From  time  to  time, 
the  women  have  pains  in  the  back,  in  the  abdomen,  frequent  desire 
to  urinate.  The  lochial  discharge,  instead  of  being  almost  nil  as  after 
completed  miscarriages,  persists,  remains  reddish,  sometimes  is  fetid: 
but  what  predominates  is  hemorrhage,  which  may  be  profuse,  even 
though  the  placental  remnant  be  small.  Finally,  the  woman  may  have 
slight  rise  of  temperature. 

(b.)  Expulsion  of  the  Placenta  Altered  and  Putrid. — 1st.  Without 
symptoms  of  septic  infection. — In  these  cases  the  marked  phenomena  are 
localized  in  the  uterus  and  its  neighborhood.  The  lochia  become 
fetid,  and  this  persists,  until  the  placenta  has  been  expelled,  either 
spontaneously,  or  by  instrumental  means.  Inflammatory  symptoms  from 
the  uterus,  or  the  adjacent  organs,  not  rarely  supervene,  but  these  are 
accompanied  only  by  slight  fever,  and  hemorrhage.  Even  as  the  lochia 
may  be  putrid  without  the  presence  of  micro-organisms,  even  so  the 
placenta  may  become  putrid  in  the  absence  of  such  organisms.  The 
alterations  are  purely  chemical  in  nature,  and  consist  in  the  production 
of  alkaloids  of  very  penetrating  odor;  fermentative  microbes  are  not 
present,  and,  therefore,  there  is  no  danger  of  serious  intoxication.  2d. 
With  septic  infection. — Degeneration  of  the  placenta  may  occur  before 
the  expulsion  of  the  foetus.  Kauffmann  has  reported  a  case  of  miscarriage 
at  the  fourth  month,  where,  before  the  expulsion  of  the  foetus,  the 
woman  had  chills,  hemorrhages,  high  temperature,  with  escape  of  putrid 
clots.  Two-thirds  of  the  placenta  remained  in  the  uterus  after  the 
expulsion  of  the  foetus,  and  the  woman  died  in  four  days,  of  septic  .fever. 

When  the  retained  placenta  putrefies,  and  septic  fever  supervenes,  it 
may  be  acute,  or  sub-acute,  from  the  start.  The  woman  may  die  quickly 
after  the  expulsion  of  the  foetus.  At  other  times,  the  progress  is 
less  rapid;  it  may  last  from  weeks  to  months,  and  end  in  cure  or  in 
death.     In  these  instances,    to    the   signs  we   have   already  noted  as 


334  A    TREATISE    ON    OBSTETRICS. 

following  on  retention  of  the  placenta,  are  joined  those  which  are 
characteristic  of  placental  putrefaction.  The  lochia  become  sero- 
sanguinolent,  blackish,  and  contain  remnants  of  placenta  or  membrane, 
intolerably  fetid.  When  injections  are  administered,  this  odor  is 
diminished,  but  it  quickly  reappears.  At  the  same  time  there  are 
symptoms  of  metritis,  metro-peritonitis,  and  all  those  of  septic  infection 
— chills,  fever,  diarrhoea,  change  in  the  appearance. 

(c.)  Absorption  of  the  Placenta. — May  this  occur?  The  fact  is  admit- 
ted by  Velpeau,  Lagemard,  Maslieurat,  and  denied  by  Madame  Boivin, 
and  others.  Hegar  has  lately  studied  the  question,  and  he  thus  tabu- 
lates the  reported  cases:  1st.  Cases  in  which  no  discharge,  either  bloody 
or  serous,  purulent  or  putrid,  has  been  observed,  in  which  the  placenta 
might  have  passed  away.  Such  are  the  cases  cited  by  Nagele,  Gabillot, 
d'Outrepont,  Villeneuve,  Porcher,    Charleston,  Maslieurat,    Lagemard; 

2.  Cases  in  which  there  has  occurred  more  or  less  abundant  discharge  of 
putrid  sero-sanguinolent  fluid.  Such  are  those  of  Salomon,  Schmidtmul- 
ler.  Burger,  Steinberger,  Kyll,  Ovalide,  Velpeau,  Dubois,  Planque,  Ingle- 
by,  Grlover,  Morlane,  Deubel,  Villeneuve,  Delpierre,  Grodefroy.  Hegar 
first  establishes  the  fact  that  cases  in  the  second  category  can  not  be  of 
placental  absorption,  and  that  they  must  be  considered  as  instances  of 
retention  of  the  placenta  with  degeneration.  But  is  this  also  true  of 
the  cases  in  the  first  category?  By  resorption  of  the  placenta  authorities 
understand  not  absorption  of  putrefied  and  loose  placentae,  but  of 
those  still  adherent  to  the  uterus,  neither  liquefied  nor  putrefied.  And 
in  the  seven  observations  noted,  the  existence  of  an  adherent  placenta 
had  been  assured.  No  uterine  or  vaginal  discharge,  containing  remnants, 
had  been  present;  on  the  contrary  the  lochia  are  said  to  have  been 
diminished,  without  odor.  Both  cord  and  membranes  had  been 
expelled.  With  the  exception  of  slight  fever,  and  a  few  after  pains, 
nothing  in  particular  was  noted.  In  five  cases  menstruation  reappeared 
from  the  seventh  to  the  thirteenth  week,  and  in  those  there  speedily 
occurred  another  pregnancy,  and  normal  confinement. 

Certainly,  at  first  sight,  absorption  seems  incontrovertible.  Hegar 
proposes  three  hypotheses:  1.  Either  the  accoucheur  was  in  error  in 
observation,  or  there  was  deception  on  the  part  of  the  patient  ;  2.  Or 
there  occurred  retention   of  the  placenta,  and  consecutive  alteration; 

3.  Or  true  absorption  took  place.  In  conclusion,  without  absolutely 
denying  the  possibility  of  absorption  he  does  not  consider  as  credible  the 
cases  heretofore  recorded.  It  is  most  likely  that  the  retained  portions 
were  liquefied,  and  broken  u]),  thus  passing  away  in  the  vaginal  excre- 
tions. 

(d.)  Indefinite  Sojourn  of  tlie  Placenta  in  the  Uterus. — It  is  granted 
by  Hegar  that  the  placenta,  and  even  the  entire  ovum,  may  remain  in 
the  uterus  even  up  to  the  death  of  the  woman.      They  undergo  retro- 


MISCARRIAGE.  335 

grade  metamorphosis,  and  this  is  the  explanation  of  those  curious  cases 
where,  after  death,  foreign  bodies,  containing  foetal  debris  more  or  less 
altered,  have  been  found  in  the  uterus  of  women  of  the  age  of  75,  80, 
and  90.  Sip  eh  are  recorded  by  Kilian,  Bohmer,  Sandifort,  Vallisnieri, 
Morgagni,  Van  Swieten,  Camerarius,  Dedek,  Niemann. 

The  Treatment  of  Miscaeriage. 

Whatever  the  causes  of  miscarriage,  we  have  seen  that  they  induce  one 
or  another  of  the  three  following  phenomena:  1.  Either  they  deter- 
mine the  death  of  the  foetus,  and  thus  necessitate  miscarriage;  2.  Or 
else  they  induce  congestions,  hemorrhages,  which,  by  causing  the  prem- 
ature detachment  of  the  ovum,  thus  compromise,  either  directly  or 
indirectly,  the  existence  of  the  product  of  conception;  3.  Or,  finally, 
they  excite  premature  contractions  of  the  uterus,  and  then  follow 
expulsion  of  the  ovum  and  of  the  foetus.  To  combat  these  causes,  such 
is  the  indication  which  the  prophylactic  treatment  of  miscarriage,  as  it 
has  been  called,  must  fulfil.  When  this  prophylactic  treatment  has 
failed,  or  has  not  been  instituted,  and  the  miscarriage  seems  inevitable, 
then,  by  means  of  the  curative  treatment  of  miscarriage,  we  still  seek 
to  stop  it,  and  thus  allow  preguancy  to  continue,  or  else,  if  we  cannot, 
to  avoid  complications,  and  to  successfully  overcome  them. 

Prophylactic  Treatment. — "The  death  of  the  product  of  conception 
within  the  uterus,  whenever  it  is  not  accidental,  or  caused  by  independent 
disease  of  the  foetus,  or  of  its  appendages,  is  the  result  of  one  of  the 
pathological  causes,  usually  hereditary  or  acquired,  which  we  have  men- 
tioned." This  sentence,  which  we  have  quoted  from  Jacquemier, 
resumes  in  a  word  the  greater  portion  of  the  indications  for  prophylactic 
treatment.  We  say  the  greater  part,  because  it  only  applies  to  those 
cases  where  the  product  of  conception  is  dead,  before  the  symptoms  of 
miscarriage  are  evident;  and  in  a  large  proportion  of  cases  the  ovum  is 
expelled  living,  and  long  before  term,  under  the  influence  of  some  local 
morbid  state  of  the  mother,  without  one  being  able  to  lay  its  death  to 
any  special  diathetic  cause.  When  this  diathesis  exists,  and  causes  the 
death  of  the  foetus,  we  must  determine  it,  and  fight  it  by  appropriate 
treatment,  before  we  allow  a  second  pregnancy.  If  the  woman  is  of 
a  lymphatic,  chloro-anemic  constitution,  we  must  have  recourse  to  tonic- 
and  strengthening  means;  the  preparations  of  iron,  or  arsenic,  sea  baths, 
hydrotherapy,  mineral  waters  containing  sulphur  or  iron,  used  as  baths 
or  douches,  quinine,  these  are  indicated;  but,  be  it  understood,  such 
treatment  must  be  continued  for  a  long  time,  in  order  to  give  good  results, 
and  a  second  pregnancy,  supervening  too  rapidly,  not  only  would  not  go 
to  term,  but  the  woman  would  lose  the  little  benefit  which  had  resulted 
from  the  treatment. 

Among  these  diatheses,  there  is  one  which  leads  all  the  others,  and 


336  A   TREATISE    ON   OBSTETRICS. 

this  is  the  syphilitic,  and  we  have  seen  already  how  frequent  it  is,  and 
also  how  deadly  to  the  product  of  conception.  We  have  seen  also  that, 
in  habitual  miscarriage,  syphilis,  possibly  latent,  either  of  the  father 
or  of  the  mother,  is  the  cause.  Anti-syphilitic  treatment,  therefore,  as 
well  for  the  father  as  for  the  mother,  especially  the  latter,  should  be 
rigorously  enforced. 

In  regard  to  syphilis,  we  would  make  the  following  statements:  1. 
Syphilis  may  be  latent  both  in  the  father  and  in  the  mother,  and  yet 
neither  possess  any  symptom,  and  it  may  be  only  the  recurrence  of  mis- 
carriages without  known  cause  which  awakens  the  suspicion  of  syphilis. 
2.  Both  father  and  mother  may  be  syphilitic,  either  recent  or  old,  and 
both  may  know  it.  3.  Very  often  the  father  alone  is  syphilitic,  and 
the  mother  is  ignorant  of  the  symptoms  she  has  had  or  still  has.  4.  In 
rare  instances  it  is  the  mother  who  is  contaminated,  and  the  husband 
has  escaped  contagion. 

In  any  instance  anti-syphilitic  treatment  must  be  resorted  to.  The 
following  is  our  practice  in  this  respect:  1.  Syphilis  is  latent,  and  there 
are  habitual  miscarriages.  We  give  a  teaspoonful  of  Van  Swieten's  liquor 
every  morning  during  four  to  five  months,  interrupting  the  treatment 
for  a  few  days  in  case  of  colic  and  gastralgia;  then  the  treatment  is 
interrupted  during  two  or  three  months,  and  resumed  for  four  weeks. 
At  the  end  of  a  few  months  we  allow  a  second  pregnancy.  2.  Syphilis 
-exists  in  both  the  father  and  the  mother.  Here  it  is  necessary  to  subject 
both  to  treatment.  3.  Syphilis  exists  in  but  one  of  the  couple.  The 
suspicions  of  the  other  must  not  be  awakened,  but  the  treatment  must 
be  as  persistent. 

[The  preparation  of  mercury  used  will  depend  on  the  preference  of  the 
individual  physician.  The  most  efficient  means  of  bringing  the  sj'-stem 
rapidly  under  the  influence  of  the  drug  is  by  inunction  with  the  oleate 
of  mercury,  and,  further,  thus  there  is  less  risk  of  interfering  with  the 
digestive  organs.  In  this  country  the  biniodide  of  mercury  is  usually 
preferred  to  Van  Swieten's  liquor,  which  is  entirely  too  irritating  to  the 
digestive  tract.  'The  necessity  of  tonic  treatment  in  conjunction  with 
the  mercurial,  should  never  be  forgotten. — Ed.] 

Under  diathetic  afi'ections,  we  would  class  ulcerations  of  the  cervix, 
and  chronic  endometritis.  Especially  is  it  of  importance  in  these  cases 
to  subject  the  woman  to  local  treatment,  in  order  to  cure  these  affections 
before  allowing  a  second  conception. 

[There  is  one  cause  of  miscarriage,  the  importance  of  which  is  not 
recognized  by  the  author,  and  this  is  laceration  of  the  cervix.  Although 
in  certain  instances,  laceration  of  the  cervix  would  seem  to  favor  concep- 
tion, because  the  cervical  canal  being  widely  open,  the  spermatozoa  have 
readier  access  to  the  uterine  cavity,  still,  remembering  that  this  laceration 
is  a  direct  irritant  to  the  uterus,  keeps  it  in  a  state  of  congestion,  and 


MISCARRIAGE.  661 

is  at  tlie  bottom  of  a  chronic  cervical  catarrh,  we  must  believe  that  this 
is  a  frequent  cause  of  habitual  miscarriage.  Many  cases  have  been 
recorded  of  late  years  where  this  habit  has  been  broken  up  through  the 
repair  of  the  lacerated  cervix.  In  any  case,  therefore,  where  this  lesion 
exists,  and  the  woman  habitually  miscarries,  the  operation  is  indicated 
as  a  prophylactic  measure. 

In  cases  of  habitual  miscarriage,  where  the  causal  factor  is  apparently 
impoverishment  of  the  mother's  blood,  the  tincture  of  the  chloride  of 
iron,  together  with  the  chlorate  of  potash,  administered  daily  throughout 
pregnancy,  will  frequently  enable  the  woman  to  go  to  term. — Ed.] 

Aside  from  diathetic  and  uterine  affections,  there  are  a  number  of 
causes  which  call  for  prophylactic  treatment.  Pregnancy  itself,  we 
have  seen,  through  the  influence  which  it  exerts  over  every  organ  in  the 
body,  predisposes  to  miscarriage,  especially  by  causing  abnormal  irritability 
of  the  uterus;  and  again,  in  certain  women,  the  uterus  is  in  such  a 
condition  of  atony,  that  it  becomes  congested  with  the  greatest  ease.  It 
is  in  such  cases  that  rest  in  bed  is  absolutely  indicated.  But  we  must 
be  careful  not  to  err  to  the  other  side,  for  too  much  rest  may  cause  loss 
of  appetite  and  weaken  our  patients.  Ordinarily,  we  only  require  our 
patients  to  stay  in  bed  at  the  time  corresponding  to  the  menses,  for  two 
days  before,  during  this  time,  and  for  forty-eight  hours  afterward. 
Usually,  at  the  fourth  month  it  is  no  longer  necessary  to  follow  this  rule. 
In  this  manner  we  have  often  been  able  to  carry  to  term,  women  who 
had  before  miscarried  a  number  of  times.  If  the  irritability  do  not  yield 
to  rest  alone,  and  if,  above  all,  the  pain  in  the  back  persists,  accom- 
panied by  slight  uterine  contractions,  then  opiates  should  be  associated 
with  rest.  Opium  should  be  administered  in  enemata  fifteen  to  twenty 
drops  morning  and  evening  for  a  few  days,  taking  the  precaution  to 
avoid  constipation.  In  women  who  object  to  enemata,  suppositories  of 
belladonna  and  the  chlor-hydrate  of  morphia  will  be  of  service.  It  is 
remarkable  the  amount  of  opium  which  the  gravida  can  take.  We  have 
often  administered  from  forty  to  one  hundred  drops  of  the  tincture  of 
opium  in  twenty-four  hours,  without  causing  narcotism. 

Phlebotomy  is  often  of  great  assistance,  and  this  too  in  women  who 
are  not  plethoric.  General  bleeding  from  the  arm  is,  in  our  opinion, 
far  preferable  to  local.  It  should  be  practiced  with  the  woman  in  the 
recumbent  position,  in  order  to  avoid  syncope.  Depaul,  Devilliers, 
Triaire,  agree  with  us  in  thinking  that  general  venesection  is  preferable 
to  local. 

In  a  certain  number  of  instances  the  means  indicated  above  do  not 
suffice.  The  symptoms  of  miscarriage,  hemorrhage,  uterine  contrac- 
tions, appear.     What  are  the  means  at  our  disposal? 

Curative  Treatment. — Miscarriage,  as  we  have  seen,  is  absolutely  in- 
evitable only  if  the  foetus  is  dead,  or  the  ovum  is  not  intact.  Up  to  the 
Vol.  II.— 23 


338  A   TREATISE    ON    OBSTETEICS. 

fourth  month,  signs  of  fcetal  death  are  absent,  and  yet  we  ought  to  act, 
always,  as  though  we  were  certain  of  the  vitality  of  the  foetus,  that  is  to  say, 
turn  all  our  endeavors  toward  preventing  the  miscarriage.  In  the  presence 
of  hemorrhage  and  of  uterine  contractions,  especially  if  neither  is 
marked,  we  must  act  quickly. 

The  first  thing  to  do  is  to  put  the  woman  to  bed,  keep  her  absolutely 
quiet,  and  administer  opium  enemata.  At  the  outset  we  give  twenty- 
five  drops  of  the  tincture  with  a  syringe,  in  order  to  be  certain  that  she 
receives  the  entire  dose.  At  the  end  of  six,  or  of  twelve  hours,  accord- 
ing to  the  urgency  of  the  case,  this  is  renewed,  and  so  on  for  twenty- 
four  to  seventy-two  hours,  if  necessary.  When  opium  is  thus  admin- 
istered continously  for  a  number  of  days,  each  morning  the  woman  should 
receive  a  large  enema  of  glycerine  and  water,  in  order  to  avoid  constipa- 
tion. 

Venesection,  on  the  appearance  of  hemorrhage,  we  cannot  quite 
counsel,  although,  if  the  woman  is  plethoric,  and  has  a  full  pulse,  with 
signs  of  congestion,  we  do  not  hesitate  to  withdraw  a  slight  amount  of 
blood  from  the  arm. 

Hohl  has  advised  the  use  of  the  sulphate  of  quinine.  Plantard,  on 
the  other  hand,  absolutely  rejects  it.  The  Italians  have  advised  tannic 
acid.  Eichardson,  and  Barnes,  the  nitrite  of  amyll.  We  prefer,  above 
everything,  laudanum,  and  if  this  fails,  but  little  can  be  expected  from 
other  means. 

[The  viburnum  prunifolium  in  drachm  doses,  repeated  every  few 
hours,  is  often  of  value  in  attempted  miscarriage.  Chloral  hydrate  may 
also  be  tried,  particularly  where  the  main  symptom  is  uterine  contraction. 
Quinine  should  not  be  used,  for  whilst  it  has  not  the  property  of  evoking 
uterine  contractions,  it  certainly  may  intensify  them  when  present. — Ed.] 

Unfortunately,  in  many  cases,  all  treatment  fails,  either  because  the 
foetus  is  dead  or  the  ovum  has  partially  separated,  or  because  the 
membranes  have  ruptured.  Then  miscarriage  is  iuevitable,  and  the 
proper  treatment  is  all-important. 

Miscarriage,  as  we  have  seen,  necessitates  hemorrhage,  and,  whilst 
usually  this  is  moderate  in  amount,  it  may  be  profuse,  and  compromise 
not  only  the  health,  but  the  life  as  well,  of  the  woman.  Whilst,  further, 
in  the  early  weeks,  the  ovum  may  be  expelled  entire,  it  may  also  be 
shed  in  two  portions,  and  the  remaining  membranes,  placenta,  or 
decidna,  may  undergo  degeneration,  and  entail  puerperal  accidents  of 
grave  import  to  the  health,  and  the  life,  of  the  woman.  AYhen  we  bear 
in  mind  the  concise  description,  already  given,  of  the  manner  in  which 
the  ovum  is  expelled,  and  how  the  phenomena  differ  according  as  the 
ovum  is  shed  entire  or  not,  according  as  the  foetus  is  alive  or  not,  it 
is  at  once  apparent  that  our  efforts  lie  in  two  directions:  1.  To  fight 
against  hemorrhage.     2.  To  end  the  miscarriage  as  soon  as  possible,  and 


MISCARRIAGE,  339 

to  avoid  retention  of  any  portion  of  tlie  ovum,  and  the  deplorable 
consequences.  These  precise  indications  are  met  very  differeutly  by 
diiferent  accoucheurs.  Certain  ones  limit  their  endeavors  to  the  control 
of  the  hemor]-liage,  assisting,  as  far  as  may  be,  uterine  contractions,  and 
thus  accelerating  the  separation,  and  the  expulsion  of  the  ovum,  never 
resorting  to  instrumental  or  manual  intervention,  except  where  placental 
retention  entails  serious  accidents.  Others,  on  the  other  hand,  insist  on 
the  necessity  of  speedy  interference,  in  order  to  stop  at  once  the 
hemorrhage,  and  to  render  impossible  the  retention  of  the  afterbirth, 
and  th3  accidents  this  entails.  These  two  methods  of  action  are 
championed  and  opposed  with  zeal.  It  is  in  particular  in  connection 
with  retention  of  the  afterbirth  that  opinion  varies  most  markedly,  the 
practice  in  regard  to  hemorrhage  being  nearly  uniform. 

Methods  of  Controlling  Hemorrhage. — When  it  is  not  profuse,  and  stays 
within  moderate  limits,  it  is  usually  sufficient  to  insist  on  absolute  rest, 
to  administer  cold  drinks,  and  to  apply  cold  cloths  over  ths  abdomen, 
and  over  the  thighs.  But,  if  it  be  serious,  if  it  be  profuse,  more 
energ3tic  action  is  requisite,  and  three  methods  are  at  our  disposal: 
1.  Administration  of  ergot.  2.  The  tamponnade.  3.  Ergot  and  the 
tamponnade  associated.     "We  prefer  this  method. 

(a).  The  Administration  of  Ergot. — This  drug,  it  is  claimed  by  those 
who  advocate  it,  has  a  double  action.  On  the  one  hand  by  exciting,  and 
increasing  uterine  contractility,  it  quickens  the  separation  of  the  ovum, 
and  the  dilatation  of  the  cervix;  on  the  other  hand,  by  causing  con- 
traction of  the  blood  vessels,  it  stops  hemorrhage.  These  two  actions 
call  for  brief  consideration.  In  order  that  ergot  may  act  forcibly  on 
the  uterine  muscle,  this  must  have  acquired  its  full  development,  and 
contraction  be  already  present.  And  these  two  conditions  are  rarely 
present  in  case  of  miscarriage.  The  uterine  muscular  fibre  is  but  little 
developed  during  the  early  months  of  pregnancy,  and,  on  the  other 
hand,  hemorrhage  is  often  profuse,  before  contraction  sets  in.  Again, 
the  contractility  evoked  by  ergot  differs  notably  from  that  Avhich  is 
peculiar  to  the  uterus;  it  is  a  species  of  tetanic  retraction,  which,  when 
it  affects  the  cervix,  not  only  does  not  cause  dilatation,  but  causes 
rigidity.  Ergot  then  may  act  directly  opposite  to  the  desired  end,  and, 
by  interfering  with  dilatation  of  the  cervix,  shut  up  the  ovum,  or  its 
remnants,  in  the  uterine  cavity.  On  the  other  hand,  it  has  been  proved 
by  the  researches  of  Parola,  of  Beatty,  of  Laborde,  and,  above  all,  of  Lee, 
and  his  pupils,  that  ergot  acts  on  the  blood  vessels,  causing  considerable, 
although  transitory,  diminution  in  the  force  of  the  circulation;  that  it 
further  acts  on  the  heart,  making  its  pulsations  more  feeble,  and  slower; 
and  that  it  also  acts  on  the  capillary  network,  determining  its  contrac- 
tion, and  diminishing  the  amount  of  blood  it  contains  in  a  notable 
manner.     Einally  it  produces  a  contraction  of  the  vessels  of  the  spinal 


340  A   TEEATISE    ON    OBSTETRICS. 

cord,  and  of  its  membranes,  decreasing  the   amount  of  blood  there 
circulating. 

Ergot,  therefore,  is  a  powerful  hemostatic,  and  should  not,  hence,  be 
rejected  in  the  treatment  of  miscarriage. 

(b.)  The  Tamponnade. — Well  applied — see  in  this  connection  the 
section  on  obstetrical  operations — it  certainly  will  stop  the  hemorrhage, 
and,  if  it  fail,  it  is  because  it  is  imperfectly  applied.  The  tampon 
opposes  the  external  appearance  of  blood,  and  thus  farors  coagulation  in 
the  uterine  cavity,  and  the  pressure  which  it  exerts  on  the  cervix, 
bladder,  and  rectum,  tends  to  increase  uterine  contractions,  and  thus 
accelerates  dilatation,  the  separation  of  the  ovum,  and  its  expulsion. 
The  sole  objection  to  it  is  the  pain  caused  by  pressure,  and  the  inter- 
ference with  the  functions  of  the  rectum  and  the  bladder.  The  danger 
of  converting  external  into  internal  hemorrhage  is  slight,  owing  to  the 
small  size  of  the  uterine  cavity  at  four  months;  and  if,  at  a  later  period 
of  gestation,  we  ought  to  watch  the  tampon  more  readily  on  this 
account,  we  still  believe  that  it  is  to  it  we  should  resort  under  conditions 
of  which  we  will  speak  later.  (See  Placenta  previa.  Vol.  III.)  We 
believe,  however,  that  there  is  a  better  method  than  the  use  of  either 
ergot  or  the  tampon  alone,  and  this  is  the  combination  of  the  two. 

(c).  Tampon  and  Ergot  Associated. — The  tampon  is  first  applied,  and 
left  in  situ,  not  a  few  hours,  as  is  the  custom  of  Barnes  and  the  Ger- 
mans, but  for  24  to  36  hours  according  to  the  case,  and  we  administer 
to  our  patients  thirty  grains  of  ergot,  in  eight  divided  doses,  at  first 
every  ten  minutes,  and  then,  after  an  interval,  every  hour.  We  prefer 
ergot  in  powder  form,  to  the  subcutaneous  injection  of  ergot,  and  we 
only  resort  to  the  latter  when  the  former  disagrees. 

[With  us  a  reliable  fluid  extract  of  ergot,  administered  in  drachm 
doses  every  three  hours,  will  be  preferred  to  the  powdered  drug.  Better 
still,  than  either,  is  the  aqueous  extract  of  ergot  by  suppository,  for  thus 
no  risk  is  run  of  causing  digestive  troubles.  An  excellent  combination 
is  the  aqueous  extract  of  ergot  (gr.  v.)  and  the  alcoholic  extract  of 
Cannabis  Indica  (^  gr.),  repeated  every  four  hours.  Cannabis  Indica, 
when  pure,  has  marked  hepiostatic  powers,  but  its  administration  should 
be  carefully  watched,  since  certain  patients  are  peculiarly  susceptible  to 
it.— Ed.] 

We  thus  obtain  together  the  effects  of  both  ergot  and  the  tampon. 
Frequently,  in  removing  the  tampon,  the  ovum  is  found  more  or  less 
engaged  in  the  cervix.  If  then  the  hemorrhage  be  slight,  and  the  con- 
tractions energetic,  the  tampon  need  not  be  reinserted,  but  the  case  may 
be  left  to  nature.  If,  however,  the  contractions  are  feeble,  if  the  hem- 
orrhage is  again  intense,  a  new  tampon  should  be  inserted,  and  ergot 
again  administered.  In  certain  cases,  where  the  ovum  is  engaged,  we 
may  simply  give  the  ergot,  since  retraction  of  the  cervix  is  no  longer 


MISCARRIAGE.  341 

to  be  feared,  for  the  ovum  in  its  canal  acts  partially  as  a  tampon,  and 
partially  from  its  irritating  efEect  on  the  cervix  determines  uterine  con- 
tractility. But,  and  this  is  a  point  of  prime  importance,  we  must  be 
careful  not  to  interfere  with  this  engaged  ovum:  it  must  be  allowed  it- 
self to  escape  from  the  external  os,  and  it  mast  never  be  extracted  until 
it  is  in  the  vagina.  Otherwise  only  a  portion  would  be  removed,  which 
would  mean  recontraction  of  the  cervix,  and  retention  of  a  portion  of 
the  ovum,  and  its  consequences. 

Unfortunately,  however,  matters  do  not  always  progress  after  the 
above  fashion,  and  in  many  instances  to  the  hemorrhage  are  joined  the 
complications  entailed  by  the  prolonged  retention  of  the  placenta,  rem- 
nants of  the  membranes,  and  of  the  decidua,  in  the  uterine  cavity.  If, 
at  times,  the  retention  of  the  placenta  means  only  more  profuse  hem- 
orrhages, the  cases  are  far  more  frequent  where  the  placenta  putrefies,  and 
determines  in  the  woman  phenomena  which  may  prove  fatal.  And 
therefore  it  is  why  every  writer  has  taken  great  interest  in  this  subject 
of  retention  of  the  afterbirth. 

At  the  outset,  one  capital  point  should  be  remembered:  In  many 
cases  the  prolonged  retention  of  the  placenta  is  admirably  supported  by 
the  woman.  It  continues  to  live  in  the  uterine  cavity,  without  altera- 
tion, and,  at  the  end  of  a  longer  or  a  shorter  time,  it  is  expelled  perfectly 
fresh,  without  other  accident  than  more  or  less  hemorrhage.  Nothing  is 
more  variable  than  the  time  during  which  this  retention  may  obtain, 
and  to  endeavor,  as  Gueniot  has  done,  to  fix  the  limit  of  what  he  calls 
normal  retention,  seems  to  us  rather  the  result  of  visionary  theory  than 
of  clinical  experience.  We  protest,  therefore,  against  this  view.  Our  col- 
league forgets  that  miscarriage  is  constituted  not  by  the  expulsion  of 
the  embryo,  but  by  that  of  the  placenta.  Miscarriage  is  simply  delivery, 
and  to  endeavor  to  set  precise  limits,  is  to  contradict  a  fact  of  experi- 
ence. Nothing  is  more  irregular  than  miscarriage,  and  the  time  requisite 
for  its  full  completion  may  vary  from  hours  to  days,  and  this  without 
further  accident  to  the  woman  than  hemorrhage,  which  we  can  control 
by  ergot  and  the  tampon. 

[In  addition  to  the  combined  use  of  the  tampon  and  of  ergot,  there  is 
a  further  agent  which  we  can  strongly  recommend,  from  the  fact  that 
it  has  been  of  marked  service  to  us,  in  cases  of  uterine  inertia,  by  invok- 
ing contractions,  by  intensifying  them,  and  thus  hastening  delivery, 
and  checking  hemorrhage.  This  agent  is  the  Faradic  current.  A  mild 
current  is  all  that  is  requisite;  the  main  point  in  its  application  being  the 
intermittency  of  its  application.  The  patient  should  hold  one  electrode, 
it  is  an  indifferent  matter  which,  and  the  other  should  be  passed  to  and 
fro  over  the  abdomen.  A  strong  current  is  to  be  avoided,  in  order  not 
to  produce  spasm  of  the  uterine  muscular  fibre.     A  further  useful  point 


342  A   TEEATISE    ON    OBSTETEICS. 

about  this  method,  is  the  fact  that  the  patient's  suffering  is  markedly 
diminished,  altliough  the  pains  are  rendered  more  effective. 

A  word  about  the  tampon  will  here  not  be  out  of  place.  As  the  au- 
thor says  with  truth,  the  tampon,  in  order  to  be  effective,  must  be  ap- 
plied well.  The  only  way  to  efficiently  tampon  the  vagina  is,  with  the 
patient  lying  in  the  left  lateral  position,  to  insert  them  through  the 
Sims  speculum.  The  posterior  cul-de-sac  should  first  be  thoroughly 
packed,  then  the  anterior,  and  finally  the  vagina  underneath.  The 
tampons  further  should  be  carbolized,  in  case  it  is  likely  they  will  re- 
main in  place  for  a  longer  interval  than  a  few  hours. — Ed.] 

We  may  have  to  face  one  of  two  conditions:  1.  The  plaiienta,  although 
in  the  uterine  cavity,  is  in  part  engaged  in  the  cervix.  2.  The  placenta 
is  entirely  in  the  cavity  above  the  cervix. 

In  the  first  instance  we  advise  ergot,  with  or  without  the  tampon, 
according  to  the  amount  of  hemorrhage;  and,  if  the  ovum  has  passed 
completely,  or  nearly  so,  through  the  external  os,  digital  extraction — 
but  only  when  we  are  perfectly  sure  it  is  not  at  all  adherent  to  the  ute- 
rus. 

In  the  second  instance,  we  make,  with  Gu6niot,  five  subdivisions:  1. 
Miscarriage  has  occurred,  but  the  afterbirth  is  incomplete,  and  there  is 
no  complication  calling  for  immediate  action.  2.  The  same  exists,  but 
with  complications.  3.  Miscarriage  has  occurred,  but  there  is  uncer- 
tainty as  to  whether  it  is  complete  or  not.  4.  Miscarriage  is  certainly 
complete,  but  there  are  complications  calling  for  interference.  5.  Mis- 
carriage is  in  progress,  inevitable,  and  more  or  less  advanced. 

At  the  outset,  it  is  apparent  that,  where  all  is  normal,  there  is  no  call 
for  interference.  All  authorities  agree  that  here  expectation  is  the 
proper  conduct.  The  difficulty  is  to  draw  the  line  where  justifiable  in- 
terference begins.  But  when  delivery  is  prolonged,  ought  we  still  to 
abstain,  ought  we  to  wait,  or  ought  we  to  interfere  actively  in  order  to 
forestall  the  complicatioas  which  almost  infallibly  will  result,  and  in- 
terfere, further,  at  a  time  when  it  is  far  easier  than  later,  when  we  may 
be  forced  to  action?  Such  is  the  problem,  the  answer  to  which  divides 
obstetricians  into  two  opposing  forces.  The  one  insists  on  active  in- 
tervention, in  order  to  terminate  the  process  as  soon  as  possible,  and 
thus  prevent  complications.  The  other,  having  deep  faith  in  the  powers 
of  nature,  only  allows  interference  in  case  of  serious  complication. 

The  following  propositions  may  be  laid  down  as  acceptable  to  all  au- 
thorities: 1.  It  is  necessary  to  interfere  in  case  of  complication,  opin- 
ions only  varying  as  to  the  manner  of  interference.  2.  In  miscarriage 
during  the  first  two  months,  since  hemorrhage  may  be  completely  con- 
trolled by  the  tampon,  and  since  the  placenta  is  small,  pliable,  and  may 
become  disintegrated  and-  discharged  in  the  lochia,  septic  complica- 
tions are  not  apt  to  be  pronounced  or  serious,  and  are  easily  mastered  by 


MISCARRIAGE.  343 

antiseptic  injections  and  tonic  treatment,  aided  by  alcohol,  and  the 
sulphate  of  quinine.  3.  At  a  more  advanced  period  of  pregnancy, 
mechanical  means  of  delivery,  other  than  manual,  are  very  difficult  of 
application,  and  expose  the  woman  to  the  danger  of  metritis,  and  peri- 
tonitis. 

In  the  first  two  months,  therefore,  retention  of  a  portion  of  the  ovum, 
no  matter  for  how  long,  calls  for  no  active  interference,  unless  serious 
accidents  supervene,  and  then  we  must  extract  these  remnants  as  soon  as 
possible.     It  is,  then,  after  two  months,  that  opinions  vary. 

Views  of  those  in  favor  of  active  interference. — To  speak  simply  of 
our  contemporaries,  we  mention,  in  England,  Tyler  Smith,  Murray,  Hall 
Davis,  Priestley,  Leishmann,  Simpson — in  Germany,  Spondly,  Betters, 
Veit  and  Fehling — in  America  Munde  [and  many  others. — Ed.] — in 
France  Gueniot.  The  reasons  given  by  Spondly,  in  favor  of  active  in- 
terference, are  similar  to  those  advanced  by  the  others.  The  frequency 
of  retention  of  the  afterbirth;  the  dangers  which  may  supervene  in  pro- 
longed delivery;  the  almost  constant  possibility  of  manual  extraction. 
Veit  is  possibly,  with  Simpson,  the  most  active  partisan  of  interference. 
If  the  cervix  is  dilated,  or  patent,  he  acts  at  once;  if  it  is  not  dilated,  he 
dilates  at  once  with  prepared  sponge,  removing  this  at  the  end  of  sixteen 
hours.  The  woman  is  then  aneesthetized,  the  uterus  depressed  as  much  as 
possible  by  the  external  hand,  and  with  the  index  finger  of  the  other  he 
removes  the  placenta  and  the  membranes.  If  he  cannot  sufficiently 
depress  the  uterus  with  the  hand,  he  does  not  hesitate  to  forcibly  drag 
it  down  by  a  double  tenaculum  fixed  in  the  cervix,  as  is  also  done  by 
Simpson,  and  Hegar  and  Kaltenbach.  It  is  evident  that  he  does  not 
always  succeed,  for  he  speaks  of  the  possible  persistence  of  hemorrhage 
after  this  method.  In  order  to  stop  this  he  washes  out  the  cavity  with  a 
solution  of  carbolic,  and  then  applies  to  the  endometrium,  the  sub-sul- 
phate of  iron,  or  pure  phenic  acid. 

Betters  and  Munde  go  further  still,  and  not  only  resort  to  Veit's 
method,  but  proceed  to  curette  the  cavity  of  the  uterus  with  Simons' 
scoop,  or  the  metal  curette  of  Thomas.  They  then  similarly  cauterize 
the  endometrium. 

[The  author  is  here  in  error,  certainly  as  regards  Munde's  practice. 
It  is  not  his  custom,  nor  indeed  of  any  of  us  in  this  country  who 
practise  interference  because  thereby  the  woman's  safety  is  at  once 
assured  and  she  herself  not  at  all  endangered,  to  use  Simons'  scoop, 
or  any  variety  of  sharj)  curette,  for  the  removal  of  the  retained  jjlacenta, 
or  shreds  of  the  ovum.  The  former,  indeed,  has  devised  the  special 
instruments  which  we  figure  below,  for  the  purpose  of  loosening  the 
adherent  placenta,  and  for  its  removal  from  the  uterus.  His  curettes 
have  no  cutting  edge,  and  are  applicable  to  cases  where  there  is  a  large 
mass  to  remove,  and  where,  in  consequence,  nearly  always  the  cervical 


344 


A   TREATISE    ON    OBSTETRICS. 


canal  is  wide  open,  and  will  hence  admit  tliem.  Where  we  are  dealing 
with  small  shreds,  and  the  os  is  less  patent,  the  dull  curette  of 
Thomas  answers  every  purpose.  As  to  whether  the  patient  will  be 
injured  by  such  instrumental  measures,  or  not,  depends  purely  on  the 
manner,  and  on  the  gentleness  with  which  they  are  resorted  to.  The 
position  of  the  woman  should  always  be  the  left  lateral,  and  the  removal 
should  always  be  through  Sims  speculum.  Then  the  cavity  should  be 
carefully  dried  by  a  cotton  applicator,  and  tamponed  by  means  of 
the  slide  applicator,  the   cotton   on  which  has  been   saturated   in  the 


Figs.  29  and  30.— MtJNcfi's  Placental  Curette.    (2  sizes.) 


compound  tincture  of  iodine.  These  manipulations  are  painless,  and 
if  performed  gently,  even  as  every  intrauterine  manipulation  should  be, 
can  do  the  patient  absolutely  no  harm.  On  the  contrary,  she  is  spared 
the  danger  from  profuse  hemorrhage,  which  might  occur  in  the  absence 
of  the  physician,  and  notwithstanding  the  ergot,  she  is  spared  the  risk 
of  septic  infection,  general  or  local,  she  is  spared  the  mental  anxiety  to 
which  otherwise  she  is  subjected.  Active  intervention  does  not  mean 
unnecessary  interference.  ISTature  is  ever  to  be  given  a  chance.  But 
when  we  see  that  her  efforts  are  futile,  certainly  it  is  but  rational  to  assist 
her  after  a  method  which,  rightly  performed,  bodes  no  harm  to  the 
patient,  but  is  full  of  good.  Those  of  our  readers  who  have  carefully 
studied  the  graphic  pen  pictures  wherein  Charpentier  delineates  the 
possible  dangers  which  may,  at  any  moment,  follow  on  prolonged  waiting, 
will  at  once  agree  that  the  procedure  advocated  in  this  country,  particu- 
larly by  Munde,  is  far  preferable,  if  it  be  only  free  from  risk,  and  this 
we  are  amply  satisfied  is  the  case.      Miscarriage  is  fraught  with  more 


MISCARRIAGE. 


345 


danger  to  the  woman  than  labor  at  term,  because,  as  Goodell  aptly  puts 

it,  the  process  is  like  plucking  immature  fruit.     We  believe,  however, 

that  timely,  active  intervention, 

resorted  to  with   care,  will  rob 

miscarriage  of  its  dangers,  and 

not  at  all   substitute  new  ones. 

American  women,  and  German 

too,  can  stand  the  practice  we 

advocate,  not  because  they  differ 

at  all    from    the    Erench,   but 

because     French     accoucheurs, 

with  scarcely  any  exception,  have 

yet  to  learn  the  manner  how  to 

assist  their  patients  rationally  in 

case  of    prolonged    miscarriage. 

—Ed.] 

Truly,  indeed,  as  Pajot  says, 
the  German  womb  is  very  slug- 
gish to  be  able  to  resist  such 
treatment,  which,  further,  it 
seems  to  us,  is  directly  contrary 
to  the  aim  of  those  who  resort  to 
it.  [His  objections  are  purely 
the  result  of  the  fact  that  the 
method  of  active  intervention  is 
not  understood.  That  the  sharp 
curette  will  wound  the  endome- 
trium, we  grant,  but  then  the 
slimy  curette  is  not  advocated, 
certainly  in  this  country;  that 
deep  cauterization  of  the  endo- 
metrium may  in  turn  produce 
trouble,  we  grant,  but  then  we 
do  not  argue  for  such  cauter- 
ixation.  The  compound  tinc- 
ture of  iodine  is  used  as  a  gen- 
tle styptic  and  disinfectant, 
and  produces  no  slough,  on  the  separation  of  which  new  hemor- 
rhage will  occur.  W%  make  these  criticisms  because  our  author, 
being  opposed  to  active  intervention,  is  not  always  just  to  the 
method. — Ed.] 


Fig.  31.— a.— Sims'  Slide 
Applicator. 


B.  —  The  same,  with 
Cotton  Tamposst  Attach- 
ed. 


346  A   TKEATISE    ON    OBSTETEICS. 

Views  of  those  Opposed  to  Active  Intervention. — The  authorities  who 
counsel  waiting  for  the  appearance  of  some  complication  before  interfer- 
ing, are  just  as  many.  We  mention:  Viardel,  Leboursier  du  (Joudray, 
Lachapelle,  Capuron.  In  England,  Eamsbotham,  Davis,  Lee,  Dewees, 
Ingleby,  Burns,  Blundell  Fleetwood  Churcliill,  Grailly  Hewitt.  In 
Germany,  Honing,  who  advises  resort  to  Kristeller's  method  of  uterine 
expression,  Martin,  Kehrer,  Hegar,  Scliroeder,  Scanzoni,  Spiegelberg. 
In  France,  all  accoucheurs,  except  Gueniot,  are  in  accord,  and  Cordes 
has  stated  the  prevalent  belief  exactly,  when  he  says:  "Miscarriage  only 
ceases  to  be  a  physiological  process,  when  the  organism  refuses  to 
tolerate  longer  the  placenta,  and  ceases  to  expel  it,  even  as  it  will  any 
foreign  body.  In  other  words,  when  uterine  contractions  supervene, 
when  the  patient  loses  blood,  when  the  hemorrliage,  or  sero-sanguinolent 
discharge,  is  fetid — then,  and  then  only,  ought  we  to  aid  the  failing 
forces  of  nature." 

To  resume,  then,  the  practice  we  would  recommend  in  case  of  mis- 
carriage: A  woman  is  miscarrying,  the  process  is  inevitable:  tampon 
and  administer  ergot,  against  the  hemorrhage.  Eemove  the  tampon  at 
the  end  of  twenty-four  hours  to  thirty-six,  if  the  contractions  are  feeble, 
at  the  end  of  eight  to  twelve  hours  if  they  are  energetic.  Then  examine 
the  cervix,  being  careful  not  to  injure  the  ovum.  If  the  ovum  is 
engaged  in  the  cervical  canal,  or  if  it  be  in  the  vagina,  and  if  it  is 
entirely  detached  from  the  uterus,  this  is  a  sine  qua  non,  remove  it  at 
once;  if  the  cervix  is  not  sufl&ciently  dilated,  if  the  ovum  has  not 
engaged,  if  it  is  still  adherent,  in  case  of  persisting  hemorrhage  reapply 
the  tampon,  and  wait. 

If  the  woman  miscarries  in  two  stages,  if  the  foetus  has  been  expelled, 
and  the  placenta  remains,  what  is  to  be  done?  Usually  nothing:  nature 
can  do  the  work,  the  placenta  may  remain  seven  to  fifteen  days,  before 
being  expelled:  whilst  there  is  no  complication,  wait,  at  least  till  the 
placenta  is  engaged  in  the  cervix  and  detached  from  the  uterus,  and 
then  extract  quickly. 

If  the  placenta  is  not  engaged,  and  the  cervix  is  closed:  wait,  and,  in 
case  of  hemorrhage,  tampon  and  give  ergot,  never  the  latter  alone. 

If  the  placenta,  still  adherent,  is  in  part  engaged  in  the  cervix:  give 
ergot,  for  the  cervix  can  no  longer  retract,  since  its  canal  is  filled  by  the 
placenta.  If  the  placenta  is  at  the  fundus,  and  adherent:  wait  still  in 
case  there  exists  no  complication;  interfere  rapidly,  in  case  of  accident. 
If  it  be  hemorrhage — the  tampon  and  ergot.  If  it  be  putrefaction  of 
the  placenta — recognize  this,  and  extract  at  once. 

How  are  we  to  recognize  putrefaction  of  the  retained  placenta  or 
membranes?  Ordinarily  this  is  an  easy  matter.  The  first  symptom 
is  fetor  of  the  lochial  discharge,  fetor  which,  at  times  is  such  as  to  per- 
meate, and  extend  beyond,  the  lying-in  room.     The  discharge,  further, 


]\rrscARRiAGE.  347 

loses  its  normal  character,  and  diminishes  in  qnantity,  becoming  black  in 
color,  or  deep  brown.  It  is  no  longer  bloody,  or  sero-sangu indent,  but 
is  composed  of  reddish-black  detritus,  the  debris  of  the  retained  mass. 
Involution  ceases,  and  the  uterus  becomes  sensitive  to  pressure.  At 
times,  slight  tympanites  supervenes,  with  or  without  diarrhoea,  and  this 
too  may  be  fetid.  The  woman  has  chills.  Sometimes  the  chill  is  vio- 
lent and  single,  sometimes  many,  separated  by  intervals  of  one  or  two 
days;  there  exists  fever,  with  elevations  even  to  104°-105°  F.  The  pulse 
ranges  to  120  and  above.  The  temperature  shows  marked  remissions, 
often,  but  the  pulse  remains  high,  and  thus  it  may  be  day  after  day, 
until  the  woman  dies.  At  times  again,  these  remissions  are  not  marked, 
the  fever  being  continuous.  The  general  condition  alters  for  the  worse, 
the  eyes  are  sunken,  anorexia,  vomiting,  and  diarrhoea  exist;  the  woman 
grows  weaker,  and,  if  we  cannot  suppress  these  symptoms,  the  woman 
dies  of  septic  poisoning. 

[A  truly  classical  picture  of  sepsis  !  Has  the  physician  any  business  to 
allow  the  woman  to  enter  into  such  a  state  ?  Is  he  doing  his  full  duty  by 
her,  when  he  sits,  with  folded  hands,  awaiting  the  onset  of  sepsis  before 
acting?  His  condition  is  one  of  armed  expectancy.  He  knows  what  he 
;Will  do  in  case  of  the  onset  of  sepsi-s,  but  action  then,  however  prompt, 
may  be  of  no  avail — the  woman  may  still  die  of  septicemia.  Seeing  then, 
that  in  no  given  case  of  retained  placenta  or  secundine  can  it  be  predicted 
whether  sepsis  will  develop,  or  not,  which  is  the  wise  course,  we  had  almost 
said  the  non-criminal  course,  to  do  at  the  outset  what  may  eventually  be 
forced  upon  us,  or  to  do  it  when  it  may  be  too  late  for  good,  and  when  cer- 
tainly action  is  far  more  difficult  ?  Again,  we  repeat,  the  immediate  re- 
moval of  the  secundines  is  safe,  and  easy,  and  guarantees  the  woman 
forthioith  against  sepsis. — Ed.] 

When  the  first  symptoms  of  sepsis  appear,  we  must  not  hesitate,  but 
we  must  immediately  extract  the  placenta,  or  the  secundines,  and  this, 
it  is  understood,  is  all  the  more  difficult  the  more  completely  the  cervix 
has  closed.  If  the  cervix  is  permeable  to  the  finger  or  to  instruments, 
the  operation  is  easy.  If  closed,  then  we  must  dilate  at  once  with 
sponge,  or  laminaria,  with  a  branched  steel  dilator,  or  with  Barnes'  bags. 
We  prefer  the  latter  in  urgent  cases.  Dilatation  once  accomplished  we 
must  proceed  to  extraction,  and  this  must  be  done  by  the  finger,  or  by 
instruments,  according  to  the  case.  We  reject  absolutely  both  traction 
on  the  cord,  and  intra-uterine  injections.  The  former  will  simply  end 
in  rupture,  the  latter  will  disinfect,  but  will  not  detach  the  secundines 
or  the  placenta.  We  further  reject,  cold  applications,  electricity,  expres- 
sion, ergot — all  these  are  too  slow. 

When  the  cervix  has  been  dilated,  the  woman  is  chloroformed,  and, 
lying  on  the  back,  the  hand  on  the  abdomen  depresses  the  uterus  as 
much  as  possible.     The  index  finger  of  the  right  hand  is  then  introduced 


348  A    TEEATISE   ON    OBSTETRICS. 

into  the  uterine  cavity  as  deeply  as  possible,  and  the  adherent  remnants 
are  detached,  and  brought  out  by  the  finger,  which  is  bent  like  a  crook. 
This  procedure  is  repeated  until  the  uterus  is  empty.  If  the  finger  do 
not  suffice,  because  the  placenta  is  too  friable,  or  firmly  adherent,  in- 
struments— ^like  Prof.  Pajot's  curette — take  the  place  of  the  finger.  The 
cavity  should  then  be  washed  out,  through  a  double-current  catheter, 
with  plenic  acid  solution,  and  these  injections  practiced  every  day,  as  long 
as  the  catheter  can  be  inserted.  Vaginal  injections  are  still  to  be  con- 
tinued by  the  nurse.  Intra-uterine  injections  must  always  be  given  by 
the  physician.  At  the  same  time,  both  quinine  and  alcohol  should  be 
administered.  Certainly  15  grains  of  the  former  should  be  given  daily — 
the  object  being  to  keep  the  patient  under  the  continuous  action  of  the 
drug. 


Fig.  33.— Articulated  Curette  of  Pajot. 

[Since  the  introduction  of  antipyrin  into  our  therapeutic  list,  it 
has  obtained  a  deservedly  high  rank  amongst  antipyretic  measures,  and 
in  all  cases  of  high  temperature  in  the  puerpera,  exclusive  of  course  of 
malarial  influences,  in  particular  when  the  rise  is  of  septic  origin,  this 
drug  should  take  the  place  of  quinine.  It  should  be  given  boldly,  prefer- 
ably by  rectum,  at  first,  and  then  repeated  in  smaller  doses  pi'o  re  nata. 
Forty  grains  by  rectum,  and  twenty  by  the  mouth  is  a  fair  average  dose 
to  begin  with.  The  drug  should  always  be  guarded  by  alcohol,  and  the 
pulse  carefully  watched,  in  order  that  digitalis  may  also  be  administered 
in  case  of  evidence  of  cardiac  failure.  The  occasional  appearance  of 
sub-norn^al  temperature,  of  urticaria-like  eruptions,  and  of  even  slight 
syncope,  should  be  borne  in  mind,  when  giving  the  agent.  These  occur- 
rences are,  however,  exceptional,  and  need  not  alarm. — Ed.] 

Alcohol  may  be  given  in  any  form.  Aconite  we  have  little  confidence 
in,  although,  in  certain  cases,  it  has  seemed  of  value.  JSTourishing  diet 
is,  of  course,  indicated. 

"We  cannot  insist  too  strongly  on  the  use  of  antiseptic  injections — in- 
tra-uterine as  long  as  odor  exists.  The  utility  of  these  injections  is  in- 
contestible. 

[In  case  the  extracted  placenta  or  seaundines  were  intensely  fetid, 
we  would  advise,  after  the  uterine  cavity  has  been  thoroughly  emptied 
and  cleansed,  the  insertion  of  a  suppository  containing  ten  to  twenty 
grains  of  iodoform.  This  may  modify,  markedly,  further  absorption  of 
septic  products.     For  the  intra-uterine  injections  we  know  of  nothing 


MISCARRIAGE.  349 

better  than  the  Chamberhiin  glass  tube,  without  the  terminal  opening. 
A  small  size,  suitable  to  miscarriage  cases,  may  be  obtained. — Ed.] 

Between  four  and  five  months,  there  is  another  complication,  at  times, 
and  this  is  where  the  foetus  presents  by  the  breech,  and  the  head,  through 
forcible  traction  on  the  breech,  is  torn  off,  and  left  in  the  uterus.  Ex- 
traction may  be  very  difficult. 

The  woman  who  has  miscarried,  should  be  subjected  to  the  same  rules 
as  those  applicable  to  the  puerpera  at  term.  Prolonged  rest  is  needed, 
and  this  is  hard  to  obtain,  for  women  are  apt  to  look  upon  miscarriage 
as  a  slight  affair.  And  after  miscarriage,  metritis,  peritonitis,  flexions 
and  versions  of  the  uterus  are  very  frequent,  and  they  may  entail  sterility, 
or  impress  the  habit  of  miscarrying. 

[All  the  more  liable  is  the  woman  to  such  affections,  when  the  treat- 
ment advocated  by  the  author  in  case  of  incomplete  miscarriage  is  the 
rule.  If  the  woman  recovers  from  the  immediate  complications  of 
the  miscarriage,  she  infallibly  possesses  a  sub-involuted  uterus,  an  endo- 
metritis, and,  if  not  at  once,  very  likely  later,  a  retroversion.  These 
are  farther  reasons,  therefore,  why  the  ultra-expectant  treatment  deserves 
condemnation.  — Ed.  ] 


CHAPTER  YI. 

EXTEA-UTEEINE  PEEGNANCY. 

jj^CTOPIC  gestation^,  doubted  by  the  ancients/ wbo^  with  their  primitive 
-^  ideas  in  regard  to  fecundation,  could  not  understand  the  possibility, 
only  assumed  rank  in  medical  literature  when  the  ovuiii  was  discovered, 
and  its  presence  in  the  ovary  attested.  The  earlier  instances  of  this 
anomaly  from  normal  gestation  were  considered  as  curiosities,  unex- 
plainable,  and  they  were  simply  noted  without  further  comment.  Certain 
accoucheurs,  Mauriceau  amongst  them,  denied  absolutely  the  possibility. 
Nevertheless,  Ambroise  Pare,  Amand,  Eoderer,  Smellie,  and  Astruc, 
have  reported  incontestable  instances. 

Levret  first  subdivided  pregnancy  into  false,  into  true,  and  into  vicious, 
when  the  foetus  is  situated  elsewhere  than  in  the  uterus.  At  the  same 
time,  Andreas  Lindemann,  distinguished  tubal,  ovarian,  and  ventral 
pregnancy.  Lauverjat,  Dionis,  and  others,  cite  examples  of  the  kind. 
It  was  only  later,  however,  that  these  apparently  super nataral  events 
received  an  explanation,  at  the  period  when  the  ovum  was  detected  in 
the  ovary,  and  from  this  time  forth,  extra-uterine  pregnancy  was  ad- 
mitted as  a  distinct  morbid  phenomenon,  and  was  carefully  investigated. 
Baudelocque,  Joseph  Jacobi  Plenk,  Stein,  Denman,  Gardien,  Oapuron, 
Velpeau,  and  others,  have  left  us  detailed  monographs.  It  was  only, 
however,  on  the  appearance  of  the  works  of  Negrier,  Eaciborsky,  and  of 
Coste,  that,  the  phenomena  of  menstruation  and  of  fecundation  having 
been  well  established,  we  possessed  a  rational  account  of  ectopic  gesta- 
tion; and,  if  now,  we  have  cause  for  wonder,  it  is  not  as  to  the  existence 
of  ectopic  gestation,  but  at  its  comparative  rarity,  dependent,  as  says 
Schroder,  not  so  much  on  the  small  number  of  fecundated  ova  which 
reach  the  abdominal  cavity,  as  on  the  fact  that  these  ova  do  not  often 
find  there  conditions  favorable  for  their  development,  and  hence  perish 
and  undergo  absorption. 

The  existence  of  ectopic  gestation  once  established,  opinions  have 
differed  widely  in  regard  to  classification;  and  since  the  days  of  Baude- 
locque, what  innumerable  varieties!  Whilst  one  or  another  form  has 
been  admitted  without  protest,  still  another  has  been  rejected.  To 
speak  only  of  ovarian  pregnancy,  it  required  the  labors  of  Coste,  Max 
Mayer,  Kiwisch,  Virchow,  Dezeimeris,  to  prove  its  possibility. 

To-day,  the  numerous  reported  cases  of  ectopic  gestation  prove,  not 
only  that  the  fecundated  ovum  may   develop   on   any  of  the   genital 


EXTRA-UTERIlSrE   PREGNAlSrCY. 


351 


organs,  even  the  cervix  (Cliavanne),  but  also  that  it  may  engraft  itself 
on  any  one  of  the  abdominal  organs,  and  undergo  all  its  developmental 
phases.  Whence  the  fact  of  the  numerous  sab-divisions,  according  to 
the  anatomical  site  of  the  ovum;  Dezeimeris  made  ten  sub-divisions, 
and  Hubert  de  Louvain  twelve;  Triadou,  in  his  work,  makes  four  sub- 


FiG.  33.— View  of  the  Left  Ovary,  in  Vertical  Section. — VW,  A'^eins  traversing  the  lateral, 
median  and  superior  borders  of  cyst.  Pla,  Portion  of  left  broad  ligament.  Pip,  Portion  of  broad 
ligament  extending  over  tlie  foetal  sac.    T,  Portion  of  the  left  tube.    K,  Foetal  cyst. 

divisions:  ovarian  (fig.  34  to  36),  abdominal  (fig.  43),  tubal  (fig.  38  to  40), 
and  interstitial  (fig.  37).  Cazeaux  admits  five  varieties:  abdominal, 
tubo-abdominal,  tubal,  tubo-uterine,  interstitial.  l^Tagele  and  Grenser 
accept  the  four  varieties  of  Triadou,  and  Schroder  agrees  with  Cazeaux, 


T\    ?.v 


Fig.  34.  FG,  Graafian  follicles.— i?.  Point  of  cyst  rupture.  Zv.  Vascular  zone  of  ovary.  K, 
Foetal  cyst  resting  on  posterior  wall.  Zx\  Remnant  of  fimbriated  extremity  of  broad  ligament.  E, 
Remnant  of  the  parovarium. 

but    adds    a    sixth    variety,    which    he    calls    tubo-ovarian,    or    tubo- 
abdominal.     Depaul,   arguing   from  a  practical,    rather  than   from  an 


352 


A    TREATISE    ON    OBSTETRICS. 


anatomical  standpoint,  makes  only  two  varieties:  tubal  and  abdominal, 
each  one  of  these  admitting  snb-division.  Thus  tubal  pregnancy  may, 
in  a  measure,  be  also  interstitial,  and  abdominal  may  be  either  primary 
or  secondary. 

In  the  first  variety  of  abdominal  pregnancy,  the  fecundated  ovum, 
instead  of  entering  the  fallopian  tube  attaches  itself  to  the  peritoneum, 
and  contracts  adhesion.  In  the  second,  the  pregnancy  was,  at  the  out- 
set, tubal,  and  it  becomes  peritoneal  when  the  tube  ruptures  in  the 
early  months,  and  the  ovam  lives  in  its  second  situation. 

Depaul  thus  excludes  a  variety  of  gestation  which  was  first  described 
by  Dezeimeris,  and  where  the  ovum  is  found  under  the  peritoneum. 


Fig.  35.— Fcetal  Sac  Open.— Pp,  Peritoneum.  Tt,  Tube  in  the  wall  of  the  cyst.  Lt,  Canal  of 
the  tube.  Ach,  Amnion  and  chorion  united.  Ck,  Cavity  of  the  foetal  cyst.  PI, Placenta.  K,  Foetal 
cyst.    Fu,  Cord.    X,  Foetus. 


The  cases  cited,  however,  by  him,  and  by  Loschge,  H^lie,  Baudelocque, 
Decord  and  Pelvet,  Saviard,  Bernard  Calvo,  Leven,  Noel,  Von  Horn, 
Lobstein,  Gallard,  Fleuriot,  Nonat,  Hecker,  and  others,  prove  its  possi- 
bility. In  ifehese  instances  the  ovum  develops  between  the  layers  of  the 
broad  ligament  independently  of  the  ovum  and  tube.  According  to 
Cauwenberge,  the  ovum  can  only  find  its  way  here  under  two  conditions: 
either  a  Graafian  follicle  ruptures  at  the  lower  border  of  the  ovary, 
which  is  not  covered  by  peritoneum,  and,  since  this  does  not  tear,  the 
very  situation  of  the  ovum  renders  impregnation  impossible;  or  else, 
it  engages  between  the  proper  covering  of  the  ovary  and  its  peritoneal 
envelope,  on  the  thin  and  irregular  border  of  a  torn  follicle,  and  the 
nature  of  the  obstacles  in  the  way  of  fecundation  of  an  ovum  in  this 


EXTRA-UTERESTE   PREGlSTATirCY. 


353 


situation,  authorizes  us  in  considering  very  rare,  if  not  in  absolutely- 
rejecting,  cases  of  this  nature.  We  would  add,  f  urtlier,  that  recent  views 
in  regard  to  the  structure  of  the  ovary,  proving  as  they  do  the  absence 
of  the  membrana  i)roiyria  of  the  ovary,  must  modify  considerably  the 
opinions  Avliich  have  been  held  in  regard  to  ovarian  j)regnancy.  The 
fecundated  ovum  must  needs  develop  in  the  interior  of  the  Graafian 
follicle,  and  the  wajls  of  the  cysts  must  be  made  uj)  by  the  thinned-out 
walls  of  the  vesicle,  and,  more  or  less,  also,  of  the  peritoneal  covering. 

Whatever  the  case,  we  may  well  limit  ourselves  to  Depaul's  classifica- 
tion— the  tubal  and  the  intraperitoneal,  for  they  are,  in  truth,  the 
only  ones  where  diagnosis  can  be  positive.  We  would  add,  further,  that 
tubal  pregnancy,  through  early  rupture,  often  kills  the  woman,  and  the 
diagnosis  is  only  made  post-mortem.     Nevertheless,  we  will  see  that  in 


FtG.  36.—PEEGNANCT  IN  A  LEFT  RUDIMENTARY  CoRNTT.  (After  Heyfelder  and  Kussniaul.)—^. 
Eight  half  of  uterus.  6,  Left  half,  c,  Vagina,  e,  Right  tube.  /,  Left  ovary,  h.  Rudimentary  cornu. 
fc,  Left  round  ligament.  Mm,  Limits  of  the  peritoneum,  n,  Left  tube,  o,  Right  ovary,  g,  Placen- 
ta,   g.  Membranes,    r.  FcEtus.    V  Right  round  ligament. 

many  instances  the  diagnosis  has  been  made  at  the  very  beginning  of  the 
pregnancy. 

To  the  above  varieties,  Keller  adds  another  form,  which  he  calls  extra- 
abdominal.  Here  the  ovum  develops  in  inguinal,  and  chiefly,  crural 
hernige.  It  is  consequently  situated  not  only  outside  of  the  uterus,  but 
of  the  true  abdominal  cavity  as  well.  Here  belong  the  cases  of  Widerstein, 
Miiller,  Skrievan,  G-enth.  Finally,  we  mention  the  cases  of  gestation 
in  the  cornu  of  a  uterus  bi-cornus — such  as  those  reported  by  Stoltz, 
Kokitansky,  Kussmaul  (fig.  37.) 

Causes  of  Ectopic  Gestation. — Here,  also,  there  is  divergency  of  opinion. 
Of  the  incontestable  causes  we  note:  Everything  which  may  interfere 
Vol.  II  —23 


354  A    TREATISE    ON    OESTETRICSo  , 

with  the  migration  of  the  ovum  into  the  tube — such  as  imperforate,  or 
congenitally  im|Derfect  tube;  its  obliteration  by  old  pelvic  inflammatory 
remnants,  by  mucus,  by  polypi;  tumors  of  the  uterus  (cases  of  Stoltz, 
of  Bohmer);  pelvic  tumors  compressing  the  tube;  pelvic  adhesions, 
occludiug  the  orifice,  or  preventing  free  movement;  organic  affections  of 
the  uterus  (cancer),  traumatism,  causing  the  rupture  of  the  uterine  wall, 
and  allowing  the  escape  of  the  ovum  into  the  abdomijial  cavity  (cases  of 
Tueiferd,  Braxton  Hicks,  etc.)  More  singular  causes  still:  that  of 
Lecluyse,  where  pregnancy  was  consecutive  to  an  antecedent  Cesarean 
section,  the  uterine  wound  not  having  healed  and  the  ovum  escaping; 
that  of  Koeberle,  where  the  body  of  the  uterus  had  been  amputated, 
and  through  a  fistulous  opening  in  the  cervix  the  spermatozoa  had 
passed,  and  fecundated  the  ovum.  This  occurred  two  years  after  the 
operation.  Finally,  moral  causes — violent  fright,  great  exertion  dur- 
ing coition,  or  immediately  after.  Velpeau  cites  such  instances.  Here, 
however,  there  is  simply  a  coincidence,  for  impregnation  does  not  occur 
at  the  time  of  coition,  but  some  time,  possibly  days,  thereafter. 

Certain  cases  might  also  be  explained  by  what  is  termed,  in  Germany, 
the  external  or  internal  transmigration  of  the  ovum,  that  is  to  say, 
where  an  ovum  expelled  by  the  ovary  of  one  side  is  caught  into  the  tube 
of  the  other.  The  cases  of  Conrad  and  of  Langhaus  would  seem  to  prove 
this.  That  this  transmigration  occurs  in  case  of  uterine  pregnancy,  is 
proved  by  the  cases  of  Eokitansky,  Oldham,  Scanzoni,  Kussmaul, 
Spaeth,  and  others.  We  mention  here,  also,  those  rare  cases  where 
both  uterine  and  extra-uterine  pregnancy  have  existed  simultaneously. 
These  have  been  recorded  by  G-oessmann,  Cook,  Landon,  Clark,  Behm 
Tuff n el  [Browne  of  Baltimore — Ed.],  and  others. 

Pathological  Anatomy. — All  authorities  are  agreed  as  to  the  ovum, 
but  when  it  comes  to  the  site  of  implantation,  what  differences!  The 
diffifulties  are,  indeed,  often  very  great,  and  interpretations  vary  accord- 
ing to  the  skill  and  the  patience  of  the  observer.  When  it  is  necessary 
to  recognize  the  ovary  or  the  tube  in  the  midst  of  exudation,  in  the 
presence  of  the  lesions  produced  on  neighboring  organs  by  the  foetal  sac, 
and  to  determine  precisely  the  point  of  implantation,  the  difficulties  are 
often  not  surmountable;  and  it  suffices  to  recall  the  instances  cited  by 
A'^elpeau,  in  order  to  understand,  how  what  one  authority  calls  an  ovarian 
gestation,  another  will  consider  tubal,  or  tubo-ovarian.  Nevertheless, 
certain  varieties  of  ectopic  gestation,  formerly  considered  inadmissible, 
are  to-day  accepted  without  protest — ovarian  pregnancy,  for  example 
(fig.  34—36). 

Now  that  we  know  that  the  ovary  is  composed  of  two  substances,  the 
one,  central,  spongy,  vascular,  the  bulk  of  the  ovary,  made  up  of  muscular 
fibres,  vessels,  and  laminated  fibres;  the  other,  superficial,  containing 
the  Graafian  follicles,  the  ovular  layer  of  Sappey,  that  is  to  say,  and  that 


EXTK A- UTERINE    PREGNANCY. 


355 


we  know  tliat  the  ovary  does  not  possess  a  tunica  albuginea,  there  can 
be  question  of  but  one  variety  of  ovarian  pregnancy — where  the  point  of 
insertion  of  the  ovum  is  in  the  Graafian  follicle  itself.  But  the  fecundated 
ovum,  in  tbe  follicle,  may  develop  in  two  ways:  If  the  follicle  is  open, 
the  ovum,  in  the  course  of  its  development,  may  project  outwardly,  so 
that  the  foetal  sac  lies  outside  of  the  ovary,  and  is  extra-peritoneal,  whilst 


Fig.  37.— Interstitial  Peegnancy.— ao.  Body  of  the  uterus,  b,  Cavity  of  the  uterus,  -wherein 
lay  the  decidua.  c.  Cavity  in  tlie  uterus,  where  lay  the  placenta,  dcld,  Fcetus,  with  the  capillaiy 
network.  c.  Vascular  portion  of  the  placenta,  still  united  to  uterus,  ff,  Fallopian  tubes,  gr,  Ova- 
ries,   ii,  Cervix,  opened  anteriorly,    fcfc,  Vagina.    (Breschet.) 


the  point  of  implantation  of  the  ovum  remains  in  the  ovary,  and  is 
intra-peritoneai;  if,  on  the  other  hand,  the  tear  in  the  follicle  closes,  the 
ovum  develops  entirely  in  the  ovary.  We  then  witness  the  same  phe- 
nomena as  in  ovarian  cysts,  only  the  growth  is  far  more  rapid.  The 
ovarian  tumor  may  contract  no  adhesions,  but,  furnished  with  a  long 
pedicle  it  carries  with  it,  in  its  growth,  its  peritoneal  covering.     This 


356  A   TEEATISE    OJST    OBSTETRICS. 

is  not  always  tlie  case,  but,  usually,  the  ovary,  containing  tlie  foetal  sac, 
contracts  adhesions  to  the  neighboring  organs.  The  tube  of  the  same 
side,  lengthened  out,  becomes  mixed  in  the  sac,  in  which  its  terminal 
fibres  are  lost.  We  can,  therefore,  no  longer  speak  of  external  and  in- 
ternal ovarian  pregnancy.  We  deal  only  with  different  phases  in  the 
development  of  ovarian  pregnancy. 

Cauwenberghe  has  studied  the  pathological  anatomy  of  ectopic  gesta- 
tion carefully,  and  we  will  adopt  his  division.  1.  The  pathological  anat- 
omy in  so  far  as  it  concerns  the  maternal  organs.  2.  That  which  concerns 
the  product  of  conception. 

1st.  Site  of  Implantation  of  tlie  Ovum — What  are  the  modifications  in 
the  maternal  organs  produced  by  the  implantation  of  the  ovum  ?  W^hen  the 
ovum  reaches  the  uterine  cavity,  it  finds  the  soil  prepared  for  it  from 
which  it  may  obtain  the  elements  indispensable  to  its  development.  The 
modifications  in  the  uterine  mucous  membrane  produced  during  menstrua- 
tion, the  swelling,  the  vascularization,  are  the  beginnings  of  the  work 
to  be  continued  by  conception,  and  the  ovum,  on  its  arrival  in  the  uterine 
cavity  finds  the  conditions  most  favorable  for  its  development.  Condi- 
tions are  very  different  when  the  ovum  engrafts  itself  in  some  other 
portion  of  the  maternal  organism.  Nature  must  ^upply  at  once  the 
elements  necessary  for  development  in  the  unusual  site.  In  a  word,  the 
ovum  must  find  not  onljr  the  site,  but  the  conditions  necessary  for  its 
development,  conditions  which  must  approach,  as  far  as  possible,  the 
normal.  Therefore,  as  soon  as  the  ovum  engrafts  itself,  a  more  thorough 
vascular  system  develops  at  the  site.  The  peritoneum  becomes  vascular, 
large  veins  appear  in  the  sub-peritoneal  tissue,  the  arteries,  in  the  neigh- 
borhood, double  in  size,  and  thus  is  formed  a  species  of  vascular  erectile 
tissue,  where  the  placenta  is  implanted  (Hohl).  Whatever  the  site,  the 
ovary,  tube,  or  abdominal  cavity,  the  modifications  are  the  same.  All 
observers  agree  on  this  point,  difference  of  opinion  being  only  in  regard 
to  the  extent  of  the  changes. 

The  genital  organs  do  not  watch  with  indifference  the  changes  occur- 
ring around  them,  but  they,  as  well,  undergo  modifications,  which  are 
evident,  even  if  not  clearly  explainable.  The  vaginal  walls  thicken,  and 
soften;  the  secretion  of  the  vaginal  mucous  membrane  increases,  the 
uterus  increases  little  by  little  in  size,  rises  in  the  abdominal  cavity,  its 
walls  thicken,  its  vessels  increase  in  size,  and  the  cervix  presents  the 
appearances  of  early  pregnancy.  Finally,  a  true  decidua  is  formed,  anal- 
ogous to  that  which  is  expelled  in  case  of  miscarriage.  At  the  same 
time,  the  breasts  alter,  and  a  true  secretion  of  milk  takes  place.  The 
two  chief  phenomena,  however,  concern  the  cervix  and  the  decidua. 

The  changes  in  the  cervix  deserve  special  notice,  for  they  may  assist 
notably  in  diagnosis.  Although  the  modifications  recall  in  a  measure 
those  which  exist  in  case  of  uterine  pregnancy,  in  the  immense  majority 


EXTRA-UTERINE   PREGNANCY. 


357 


of  cases  they  are  not  in  harmony  with  the  period  of  pregnancy.  The 
cervix  softens,  and  the  external  os  changes  a  little,  but  only  in  so  far  as 
usually  happens  in  the  first  two  months  of  gestatio7i.  The  lower  portion  of 
the  organ  is  alone  affected.  The  internnl  os  remains  closed,  even  in  multi- 
para3,  and  the  consistency  of  the  cervix  is  more  like  that  of  a  nou-preguant 
woman,  than  of  a  pregnant.  Whilst,  further,  in  normal  gestation  the 
cervix  is  usually  situated  behind,  and  to  the  left,  owing  to  the  right 
lateral  inclination  of  the  uterus,  in  ectopic  gestation  the  cervix  usually 
lies  in  front  and  above.  This  is  a  point  strongly  insisted  upon  by  De- 
paul. 

As  for  the  decidua,  it  is  usually  found.  Where  the  decidua  has  not 
been  noticed  in  certain  reported  cases,  this  is  because  it  was  very  thin, 
or  else  had  already  then  expelled.     The  modifications  which,  in  normal 


Fig.  38.— Interstitial  Pregnancy.    (Poppel.) — CO,  Cavity  of  ovum.    6,  Placenta,    v.  Chorionic 
villi.    LR,  Round  ligaments. 

gestation,  occur  in  the  uterine  mucous  membrane  in  order  to  form  the 
decidua,  are,  according  to  Cauwenberghe,  independent  of  the  ovum. 
These  changes  begin  even  before  the  ovum  has  reached  the  organ.  Fur- 
ther, this  membrane  is  esssentially  transitory.  At  first  voluminous,  it 
soon  becomes  the  seat  of  true  atrophy,  of  active  absorption,  and  this  ex- 
plains why  at  term  scarcely  any  traces  often  remain.  It  may  be  asked, 
then,  if,  in  extra-uterine  pregnancy,  this  useless  decidua  will  not  un- 
dergo the  same  atrophy,  this  same  absorption,  which  results  as  soon  as 
it  is  no  longer  necessary  to'  the  development  of*  the  ovum,  in  normal 
cases;  and  why,  furtlier,  in  similar  cases  the  retrogressive  phenomena 


368 


A   TREATISE    ON    OBSTETRICS. 


will  not  occur  more  rapidly  in  certain  cases  than  in  others,  and  if  we 
may  not  thus  explain  the  instances  where  the  decidua  has  been  lacking 
— for  such  instances  exist.  It  is  particularly  in  case  of  abdominal  ges- 
tation that  the  increase  in  the  size  of  the  body  of  the  uterus  has  been 
denied,  as  well  as  the  formation  of  the  decidua;  there  exist  a  number 
of  authentic  observations  of  this  nature  on  record.     (Fleury,  Depaul.) 

It  is  accepted,  however,  that  this  decidua  exists  in  extra-uterine  preg- 
nancies, but  this  decidua  can  only  form  in  the  uterus,  and  those  authori- 
ties who  have  searched  in  the  ovary,  and  in  the  tube,  and  even  around 
the  ovum  for  the  decidua,  could  not,  of  course,  find  it,  for  it  does  not 
exist  there.  It  is  through  sympathy  that  the  uterus  produces  the  de- 
cidua, and  it  alone  can  make  it,  for  it  alone  possesses  a  mucous  membrane 
from  which  it  can  be  formed.     And  this  is  so  true,  that  the  further  from 


Fig.  39.— Tubal  Pregnancy.— OD,  Right  ovary.    TD,  Rignt  tube. 
Foetal  sac.    OG,  Left  ovary.  TG,  Left  tube.    CS,  Clots. 


CS 


la 


t7,  uterus.    iT,  Hydatid.  ST, 


the  uterus  the  point  of  implantation  of  the  ovum,  the  less  is  the  decidua 
developed;  and  it  is  exclusively  in  case  of  abdominal  gestation  that  its 
absence  has  been  noted. 

Schroeder,  however,  claims  that,  in  case  of  tubal  gestation,  the  mucous 
membrane  of  the  tube  swells  similarly  to  that  of  the  uterus,  and  that  a 
normal  decidua,  frequently  also  a  reflexa,  forms  there.  The  appearance 
may  be  the  same,  but  the  structure  differs;  for  the  mucous  membrane 
of  the  uterus  alone  possesses  the  peculiar  glands  and  special  cells  which 
play  so  great  a  part  in  the  evolution  of  the  decidua,  and  the  mucous 
membrane  of  the  tube,  notwithstanding  its  swelling,  can  never  present 
the  histological  structure  of  the  uterine  decidua.  Contrary,  therefore,  to 
the  opinion  of  Lee,  Fleetwood  Churchill,  Breslau,  and  others,  we  cannot 
admit,  in  tubal  pregnancy,  the  presence  of  a  true  decidua  in  the  tube. 


EXTRA-UTERINE   PREGNANCY. 


359 


and  the  microscopic  appearances,  described  by  Conrad  and  Langhaus, 
seem  entirely,  to  prove  this. 

2d.  Anatomy  oftlie  Foetus  and  its  Annexes. — Here  there  is  no  difference 
in  opinion.  The  embryo  always  possesses  its  two  peculiar  membranes — 
the  chorion  and  the  amnion,  at  least  during  its  period  of  development, 
and  it  can  not  be  otherwise:  each  is  inherent  to  the  very  evolution  of 
the  ovum,  each  is  a  direct  outgrowth  from  the  ovum;  without  them  the 
ovum  can  neither  exist  nor  develop.  Where  difference  of  opinion  begins 
is  in  regard  to  the  elements  which  constitute  the  protecting  envelope 
around  the  product  of  conception,  as  it  grows  in  its  abnormal  site. 

In  Ovarian  Pregnancy,  the  ovum  develops  in  the  thickness  of  the 
Graafian  follicle. 

In  Interstitial  Pregnancy,  it  is  the  substance  of  the  uterus  itself  which 
forms  the  bed  of  the  o\T.im  and  its  membrane. 

In  Tubal  Pregnancy,  it  is  the  walls  of  the  tube,  and  the  peritoneum. 


Fig.  40.— Pregnancy  in  Left  Tube.    (Spiegelberg,  after  Sommer.) 


In  Aldo7ninal  Pregnancy,  two  alternatives  offer:  the  pregnancy  is  either 
primary  or  secondary.  In  the  first  case,  where  the  ovum  escapes  from 
the  Graafian  follicle,  instead  of  entering  the  tube  it  falls  into  the  abdom- 
inal cavity,  and  there  engrafts  itself  at  some  point,  and  undergoes  de- 
velopment. Dezeimeris  is  wrong  when  he  denies  the  existence  of  a  pro- 
tecting cyst.  All  authorities  agree  that  it  exists,  and  it  has  been  de- 
scribed by  Jacquemier,  Kiwiscn,  Gerlach,  Hohl  and  others.  This  cyst 
may  vary  according  to  the  variety  of  pregnancy,  and  to  sjoeak  only  of 
the  sub-peritoneal  pelvic  variety,  which  is  almost  always  secondary,  the 
cyst  is  exclusively  formed  of  peritoneum;  at  times,  however,  a  jDortion  of 
the  uterus,  deprived  of  its  abdominal  serous  coat,  enters  into  the  formation 
of  the  sac. 

Usually,  the  formation  of  the  cyst  is,  even  as  the  pregnancy,  necessarily 
secondary,  and  the  following  are  the  stages:  Originally  interstitial,  or 
tubal,  or  ovarian,  the  cyst  ruptures,  and  then  either  the  ovum  remains 
in  place,  the  membrane  alone  projecting  through  the  rupture  site,  or  else 


360 


A   TREATISE    ON    OBSTETRICS. 


it  falls  entire  into  tlie  abdominal  cavity.  In  both  instances  rupture  is 
accompanied  by  hemorrhage^  which;,  often  fatal,  may  at  times  be  limit- 
ed, and  the  woman  recover.  The  exuded  blood  becomes  organized;  a 
new  membrane  is  formed  which,  merging  into  the  true  cyst  wall,  renews 
it.  Again,  it  may  be  the  clot  which  becomes  organized  and  repairs  the 
rent. 

Often  finally,  during  the  course  of  an  extra-uterine  pregnancy,  an 
exudation  occurs  around  the  cyst,  and  this  forms  a  second  sac,  surround- 
ing the  first  more  or  less.  The  ovum  is  thus  enveloped  in  two  mem- 
branes, and  resists  the  better  external  influences:  the  internal  cyst  may 
alter  without  danger  to  the  mother,  and  the  foetus,  thus  protected,  de- 
velops the  better. 

Finally,  in  any  variety  of  ectopic  gestation,  and  even  uterine,  the  prod- 
uct  of  conception  may,  through  change  in  the  gestatory  organ,  pass 


Fig.  41.— Tubal  Pregnancy,  with  Fibrous  Tumors.    (After  Harley.) 


into  the  peritoneal  cavity,  whilst  the  placenta  remains  attached  to  the 
site  where  the  ovum  was  implanted.  Ordinarily  the  foetus  dies,  neverthe- 
less there  are  many  recorded  instances  where  it  lived.  In  Walther's  case, 
for  example,  ovarian  pregnancy,  the  foetus  developed  for  four  months 
amidst  the  abdominal  viscei^a,  and  was  found,  at  the  end  of  gestation,  as 
free,  and  without  cyst,  as  at  the  time  of  its  escape  from  the  ovary. 

Triad  on  has  recorded  a  case  of  Eichet's  (ovarian),  where  microscopic 
examination  by  Jouon,  revealed  the  following  nature  of  the  cyst:  Com- 
posed of  a  cellular  layer,  with  vessels,  thicker  in  the  posterior  than  in  the 
anterior  wall.  Of  another  layer  ^  of  an  inch  in  thickness,  composed  of 
epithelial  cells  with  very  large  nuclei.  Of  a  further  layer,  tV  of  an  inch 
in  thickness,  composed  of  connective  pigmented  tissue.  Finally  of  a 
granular  fat  layer,  in  contact  with  the  amnion,  and  inclosing  fat  debris, 
and  other  not  recognizable  elements. 


EXTRA-UTEKINE   PREGNANCY. 


361 


The  Placenta. — This  diJEfers  from  that  of  normal  pregnancy,  in  situa- 
tion, in  shape,  and  in  vokime.  In  its  situation  there  is  no  regularity, 
although,  from  the  researches  of  Koeberle,  it  would  seem  frequently  to  be 
attached  to  the  anterior  wall  of  the  abdominal  cavity.  In  volume  and 
in  form  it  differs  markedly.  Sometimes  it  is  double,  and  triple  the 
size  of  the  ordinary  placenta;  sometimes  it  is  much  thicker;  sometimes 
it  is  spread  over  a  large  extent  of  surface;  sometimes  it  is  divided  into 
a  number  of  vascular  portions,  distributed  over  many  of  the  abdominal 
viscera.  The  insertion  of  the  cord  is  usually  central,  but  there  is  noth- 
ing constant  about  this.     The  manner   of  placental   insertion   differs 


"^^■ 


.';^'' 


J^ 


f  iGt.  42.— Abdominal  Pregnancy.  (After  Dreesen.) — a,  Aaus,  b,  Vagina,  c,  Bladder,  d,  Os  uteri, 
e,  Fundus  uteri.  /",  Broad  ligament,  g.  Left  tube,  h,  Cecum,  ii,  Intestines,  kk.  Peritoneal  ad- 
hesions. 


scarcely  at  all  from  the  normal,  and  the  placental  villi  float  in  trenches 
filled  with  blood  analogous  to  the  uterine  sinuses.  In  tubal  pregnancy, 
according  to  Kiwisch  and  Oldham,  there  exist,  at  least  in  the  first 
months,  ramification  of  the  villi  and  the  maternal  blood  vessels,  very 
much  like  the  disposition  of  the  placental  vessels  in  carnivorae. 

TJie  Foetus. — Up  to  term,  the  foetus  develops  even  as  in  normal  preg- 
nancy; but  when  the  foetus  has  gone  beyond  term  in  the  abdominal  cav- 
ity, it  may  assume  very  different  appearances.  Occasionally  it  lives 
beyond  term,  as  is  attested  by  the  cases  of  Grossi,  Schmidt,  B'ayle,  and 
others,  and  then  it  corresponds,  in  appearance,  to  the  stage  of  gestation — 


362 


A   TREATISE    ON    OBSTETRICS. 


advanced  ossification  of  the  skeleton,  teeth,  etc. ;  again,  it  is  purely  like 
an  infant  born  normally  at  term.  These  instances  are,  however,  excep- 
tional. Usually,  the  foetus  dies  before  term,  or  at  term;  and,  if  the  mother 
survives,  it  undergoes  manifold  changes.  Lempereur  has,  especially, 
studied  these  changes.  "After  having  established  the  fact  that,  in  nor- 
mal pregnancy,  the  foetus,,  according  to  the  period  at  which  it  dies,  un- 
dergoes dissolution,  mummification,  and  maceration,  he  studies  the  altera- 
tions which  occur  in  case  of  prolonged  uterine  gestation.  He  admits, 
at  the  outset,  that  prolongation  of  uterine  pregnancy  is  possible,  as  is 
attested  by  the  observations,  in  cows,  sheep,  rabbits,  of  Sherman,  Bout- 
rolle,  Huzard,  and,  in  the  human  species,  of  Oldham,  Cheston,  Bompar, 
Penker,  Shorland,  Harris,  Schultz,  etc.     He  shows  that,  ir  such  cases. 


Fig.  43.-TRANSFORMATION  OF  FcETUS  INTO  A  LiTHOPEDioN.-a,  Calcareous  capsule.    6,  c,  Vessels 
on  the  wall  of  the  cyst,    d,  e,  p,  </,  /i,  i,  Foetal  parts. 

Fig.  44— ExTfiA-UTERiNE  Pregnancy.— Transformation  of  the  foetal  cyst. 

the  fa3tus  may  undergo  maceration,  and  putrid  decomposition  in  case  there 
is  access  of  air  to  the  uterus,  mummification,  ossification,  and,  finally,  sap- 
onification. Passing  then  to  ectopic  gestation,  he  shows  that  the  altera- 
tions are  similar.  Kejecting  the  dermoid  cysts  as  products  of  conception, 
he  shows  that,  in  the  early  months,  dissolution,  mummification,  and  ma- 
ceration, may  take  place— in  a  word,  the  changes  peculiar  to  intra-uterine 
gestation.  The  foetus,  further,  may  undergo  other  changes— such  as 
changes  into  adipocire,  or  steatose.  Through  organic  adhesions  to  the 
maternal  organs,  this  foetns  lives  a  parasite  at  the  expense  of  the  mother. 
These  adhesions,  however,  allow  only  imperfect  nutrition,  and  fatty  de- 


EXTRA-UTERINE   PREGNANCY.  363 

generation  sets  in."  Whence,  according-  to  Cauwenberghe,  retrograde 
metamorphosis,  progressive  atrophy,  whicli  may  result  in  calcareous  de- 
generation or  ill  comjjlete  disappearance  of  the  soft  parts,  and  only  the 
skeleton  remains  (iig.  43  and  44),  It  is  understood,  then,  that  the  foetus 
may  remain  for  years  in  the  abdominal  cavity,  without  risk  to  the  mother, 
and  all  authorities  give  examples  of  the  lithopedion.  The  best  known  is 
that  of  Leinzell,  which  was  found  in  1720  in  a  woman  of  94,  who  had  car- 
ried it  for  46  years.  In  certain  exceptional  cases,  the  foetus,  although 
dried  up,  is  so  well  preserved  that  the  tissues  have  their  normal  structure. 
(Cases  of  Wagner  and  of  Virchow.) 

It  is,  especially,  in  abdominal  pregnancy  that  these  transformations 
are  noted. 

Symptomatology  and  Progress. — It  is  only,  as  Depaul  says,  by  ac- 
cumulating observations,  and  carefully  studying  those  cases  where 
there  has  been  error  in  diagnosis,  \hat  we  can  hope  to  establish  the 
differential  diagnosis  of  ecto]3ic  gestation,  and  all  authorities  agree  in 
the  statement  that,  in  the  early  months,  this  is  almost  impossible. 
Nevertheless,  there  are  a  number  of  symptoms  which  are  well  nigh 
constant.  Usually,  during  the  first  days  following  conception,  there  are 
present  the  symptoms  peculiar  to  pregnancy — the  nausea  and  vomiting, 
the  longings,  salivation.  Vomiting  is  slower  to  appear,  and,  at  times, 
ceases  abruptly,  without  discernible  cause.  These  symptoms  are, 
however,  insufficient.  The  menstrual  phemonena  are  of  higher  value. 
All  authorities  insist  on  important  modifications  in  regard  to  menstrua- 
tion. Suppression,  even  as  in  uterine  pregnancy,  exists,  but  this  sup- 
pression is  less  constant.  Sometimes,  the  menses  persist  during  the  first 
months,  and  are  normal  in  regard  to  time  and  durktion,  and  only 
disappear  later;  again  there  is  suppression,  at  the  outset,  then  they 
reappear,  only  to  disappear  again.  In  any  event,  women  at  times 
conceive  again,  and  bear  to  terra  one  or  more  healthy  children,  whilst  the 
foetus,  developed  or  not,  remains  in  the  abdominal  cavity.  Usually 
bloody,  or  sero-sanguinolent  discharges,  mixed  w^ith  mucus,  take  the 
place  of  the  menses.  Accompanying  them  are  colicky  pains,  and  in  the 
discharges  it  is  not  uncommon  to  find  pseudo-membranous  d6bris,  the 
remnants  of  the  decidua.  These  discharges  reapjDcar  when  the  foetus 
attains  term,  and  when  false  labor  sets  in,  and  Duguet  is  inclined  to 
think  that  the  expulsion  of  the  decidua  corresponds  to  the  death  of  the 
foetus.  The  case  he  reports  would  seem  to  prove  this.  But  such  is  not 
always  the  case,  for  the  dec^'dua  may  be  shed  a  longer  or  shorter  time 
before  labor,  and  this  v/ill  explain,  in  a  measure,  its  absence  in  those 
cases  where  it  has  not  been  noted,  Duguet  is  further  inclined  to  think 
that  these  hemorrhages  are  especially  marked  in  case  of  tubal  pregnancy. 
Another  symptom,  which  certain  observers  consider  pathognomonic,  is 
a  peculiar  pain,  very  variable,  in  site,  in  intensity,  in  appearance — often 


364  A    TREATISE    ON    OBSTETRICS. 

appearing  at  the  beginning  of  pregnancy^  usually  it  is  only  at  the  end  of 
about  three  months  that  it  is  noted.  At  first  dull,  a  simple  sensation  of 
weight,  of  abdominal  tension,  generalized,  it  later  becomes  localized  at 
the  umbilicus,  or  in  the  inguinal  or  sacral  regions,  and  thence  irradiates 
into  the  thighs  and  legs.  Walther  says  that,  in  one  of  his  cases,  the 
pain  was  so  intense  that  the  patient  only  found  relief  in  the  knee-chest 
position,  and  that  the  least  motion  caused  her  to  utter  awful  shrieks. 
Often  continuous,  except  when  the  abdomen  is  palpated,  when  it 
increases  in  intensity,  this  pain  is  subject  to  exacerbations  dependent  on 
varying  causes.  At  times  the  access  is  accompanied  by  discharge  of 
clots,  and  decidual  debris.  The  pain  is  then  like  that  of  miscarriage, 
intermittent,  irregular,  like  true  uterine  colic,  which  disappears  only 
concurrently  with  profuse  hemorrhage.  Again,  the  pain  is  like  that  of 
peritonitis,  and  seems  dependent  on  localized  attacks,  which  are  not 
sufficient  to  cause  the  death  of  the'woman,  but  result  in  the  formation 
of  adhesions,  and  false  membranes,  which  bind  the  foetal  cyst  to  the 
neighboring  organs.  Finally,  sooner  or  later,  these  pains  increase  in 
intensity,  are  accompanied  by  tearing  sensations,  and  symptoms  of 
internal  hemorrhage:  these  are  the  first  symptoms  of  rupture  of  the  foetal 
sac.  These  last  symptoms  may  appear  suddenly,  whilst  the  woman  is 
enjoying  good  health,  and,  of  a  sudden,  she  is  at  the  point  of  death. 
The  pain,  further,  may  diminish,  instead  of  increasing  with  the 
progress  of  gestation.  Usually  it  persists  until  the  foetus  dies,  -ind  then 
ceases;  occasionally  it  is  present  until  the  foetus  has  been  expelled  or 
extracted. 

When  gestation  proceeds  to  term,  pains  of  another  character  supervene. 
These  are  tlibse  of  labor,  returning  with  the  intermittency  and 
periodicity  of  true  uterine  contractions.  In  appearance  a  true  labor,  it 
is  in  reality  a  false.  It  may  last  two  to  three  days,  be  followed  by 
absolute  remittency,  and  reappear  again  at  variable  intervals.  Usually 
the  death  of  the  foetus  coincides  with  this  false  labor;  but  it  is  not 
always  so,  and  the  observed  cases,  where  the  foetus  has  lived  several 
months  beyond  term,  justify  our  assertion. 

Finally,  in  a  number  of  instances,  these  pains  have  lasted  even 
longer.  In  a  case  recorded  by  Hold,  they  reappeared  every  four  weeks, 
until  the  return  of  the  menses.  In  Schmidt's  case,  they  reappeared 
eight  times,  during  the  eight  years'  retention  of  the  foetal  sac.  Lospikler 
(a   six  years'  case)  witnessed  their  return  every  year. 

What  is  the  true  cause  of  the  pains?  Must  we,  with  Dezeimeris,  seek 
it  in  uterine  contraction?  Does  it  reside  in  contractions  of  the  foetal 
cyst?  It  has  been  proved  that  the  foetal  sac  contains  numerous  muscular 
fibres,  and  the  assertions  of  Zwanck,  of  Naegele,  of  Eapin,  of  Baudelocque, 
of  Hohl,  that  they  have  seen  the  sac  contract,  cannot  be  doubted.  This 
fact,  however,  does  not  exclude  the  uterus  from   contracting  through 


EXTRA-UTERINE    PREGNANCY.  865 

sympathy;  and  although  Hohl,  by  introducing  a  sound  into  the  uterus, 
during  violent  pains,  found  absolutely  no  contraction  of  this  organ,  we 
believe  with  Cauwenberghe  that  the  increase  in  size  of  the  uterus,  the 
hypertrophy  of  its  muscular  tissue,  the  presence  in  the  cavity  of  numer- 
ous membranous  remnants,  and  of  old  and  new  clots,  the  expulsion  of 
the  decidua,  the  production  of  even  profuse  hemorrhage  coincidently 
with  the  pains,  which  decrease  with  the  emptying  of  the  uterus — that 
these  facts  prove  that  the  organ  plays  a  part  almost  equal  to  that  of 
the  sac  in  the  production  of  the  pains. 

To  th6  above  probable  signs,  are  joined  certain  which  may  almost  be 
termed  absolutely  diagnostic.  These  are  furnished  by  the  local  exam- 
ination. 

1st.  External  Examination. — By  this  means  we  may  determine  the 
presence  of  a  tumor  in  the  abdomen,  a  tumor  which,  unlike  the  uterus, 
does  not  occupy  the  median  line,  but  lies  usually  to  the  right  or  left, 
and  further  which,  instead  of  presenting  the  soft  and  elastic  feel  of  the 
gravid  uterus,  is  harder,  more  resisting,  and  above  all  painful  to  pressure. 
Varying  in  size  from  that  of  a  nut  to  that  of  an  orange,  this  tumor 
tends  ever  to  increase,  and  soon  palpation  determines  the  presence  of 
foetal  parts,  and  of  active  foetal  movements,  whilst  auscultation  reveals 
the  foetal  heart. 

[Be  it  ever  remembered,  however,  that  the  gravid  uterus,  after  the 
third  month,  when  it  appears  above  the  pelvic  brim,  reveals  to  the 
palpating  hand  those  intermittent  uterine  contractions,  which  are 
characteristic  of  the  uterus  containing  an  ovum,  which  are  absent 
always  when  we  are  dealing  with  an  ectopic  gestative  cyst,  and  which 
phenomenon  at  once,  when  appreciated,  tells  us  that  we  are  palpating  the 
gravid  uterus,  and  nothing  else.  Of  course  there  may  also  exist  an 
ectopic  gestation,  for  the  two  forms  may  coincide;  but,  we  would 
strongly  insist,  that  the  presence  of  intermittent  uterine  contractions, 
appreciable  to  the  hand  of  the  accoucheur,  means  uterine  pregnancy, 
and  their  absence  negatives  uterine  pregnancy.  In  very  obscure  cases, 
this  sign,  by  its  absence,  will  give  us  the  courage  to  prove  the  uterus 
empty  by  means  of  the  sound. — Ed.] 

Such  is  not  always  the  course  of  events.  The  tumor  may  suddenly 
disappear,  and  acute  pain,  and  the  signs  of  internal  hemorrhage,  followed 
by  sudden  death,  leave  us  in  doubt,  except  in  case  of  autopsy,  of  the 
nature  of  the  tumor. 

As  the  tumor  develops,  it  changes  in  shape;  its  outline  is  less  distinct; 
fluctuation  is  apparent;  and  we  may  obtain  true  abdominal  ballotement. 

The  cases  where  diagnosis  is  relatively  easy,  are  very  rare,  and  then  we 
have  to  depend  on  other  symptoms,  still  from  the  side  of  the  abdomen. 
In  case  of  ectopic  gestation,  the  abdomen  is  more  tense.  The  tumor  is 
irregular,  not  spherical,  and,  if  we  are  able  to  palpate  carefully,  two 


366  A    TEEATISE    ON    OBSTETRICS. 

tumors  may  be  distinguislied — the  one  smaller,  resistant,  elastic,  like 
tlie  gravid  uterus  at  two  to  three  months,  the  other  larger,  irregular, 
projecting,  in  which  ballotement,  or  the  foetal  parts,  are  readily  apparent. 
Palpation,  however,  is  often  impossible  except  under  anesthesia,  [and  in 
view  of  the  safety  of  ether,  in  any  case  at  all  doubtful,  anesthesia  should 
be  resorted  to. — Ed.] 

By  means  of  percussion  we  learn  scarcely  anything.  As  for  ausculta- 
tion, we  may  affirm,  if  we  hear  the  foetal  heart-beat,  that  we  are  deal- 
ing v.'ith  pregnancy.  The  uterine  souffle  is  often  absent  in  ectopic 
gestation.  [Similarly  is  it  often  absent,  or  not  heard,  in  case  of  uterine 
gestation.  A  similar  souffle  has  often  been  detected  over  uterine 
fibromata  and  ovarian  cysts.  The  value  in  diagnosis,  therefore,  of  ab- 
sence of  the  souffle,  is  very  slight. — Ed.] 

2d.  Internal  Examination. — Depaul  believes  that  it  is  by  means  of  the 
touch  we  will  obtain  the  most  positive  information.  If  the  uterus 
increases  in  size,  it  is  never  as  in  normal  pregnancy.  Its  tissue  becomes, 
true  enough,  softer,  more  boggy,  but  never  in  proportion  to  the  age  of 
the  supposed  gestation.  The  form  is  not  spherical,  but  flattened,  and 
far  from  sinking  into  the  pelvic  cavity  in  the  early  weeks,  it  tends  to 
rise  to  the  right  or  left,  or  behind  the  symphysis.  According  to  Depaul 
the  latter  is  the  usual  position. 

The  cervix  undergoes  changes,  but  these  are  never  as  marked  as  in 
ordinary  gestation,  and  the  changes  further  do  not  correspond  to  the 
period  of  pregnancy.  It  deviates  with  the  uterus,  to  the  right  or  left, 
usually  behind  the  symphysis,  so  as  to  be,  at  times,  inaccessible  to  the 
finger.  (Depaul.)  When  the  finger  can  reach  it,  we  may  observe 
softening  and  patency  of  the  external  os,  the  more  readily  in  cases 
where  the  woman  has  previousl}^  borne  children;  but  at  the  end  of  a 
certain  time  these  changes  disapjDcar,  especially  when  the  foetus  dies,  as 
though  the  uterus  underwent  retrogressive  changes. 

As  the  gestation  progresses  the  cervix  becomes  more  and  more  inac- 
cessible, and  we  simply  feel  through  the  vagina,  a  larger  or  smaller 
mass,  more  or  less  immovable,  through  which  it  is  sometimes  possible 
to  perceive  more  or  less  resisting  or  voluminous  parts.  This  tumor,  in 
certain  cases,  may  fill  the  whole  pelvis,  lying  at  times  behind  the  uterus, 
at  times  between  it  and  the  bladder, 

B.  Rectal  Examination. — This  gives  more  precise  information  in 
regard  to  the  form,  the  volume,  and  the  position  of  the  uterus,  and 
the  dimensions  of  the  tumor. 

Such  are  the  signs  ordinarily  attainable.  There  are  two,  in  particular, 
on  which  Depaul  lays  great  stress.  The  one,  is  the  fact  that  the  foetal 
parts  discernible  are  more  superficial  than  in  ordinary  pregnancy,  in 
certain  cases  it  seems  as  though  they  were  just  under  the  skin,  so  that 
the  head  may  be  distinguished  from  the  breech;    the   second  is  the 


EXTRA- UTERINE  PREGXANCY.  367 

peculiar  form  of  the  tumor,  its  transverse  diameter  is  longer  than  its 
vertical,  and  the  tumor  inclines  rather  to  the  left  than  to  the  right, 
whilst  in  uterine  pregnancy  the  reverse  is  generally  the  case. 

[These  signs  are  also  open  to  doubt.  In  uterine  pregnane}'',  the 
Avails  of  the  uterus  may  be  so  thinned  out  as  to  give  to  the  hand  the 
sensation  of  the  foetal  parts  being  immediately  underneath,  and  again  in 
abdominal  pregnancy,  of  which  it  is  ordinarily  question  when  gestation 
has  advanced  far  enough  to  allow  j)alpation  to  be  of  value,  the  walls  of 
the  sac  may  be  so  thickened  as  to  interfere  with  our  feeling  the  foetal 
parts  at  all.  Further,  in  case  of  transverse  presentations  in  uterine  preg- 
nancy the  transverse  diameter  is  increased  over  the  vertical,  and  if  the 
breech  of  the  foetus  lies  in  the  left  uterine  segment,  so  will  the  inclination 
of  this  organ  be  the  reverse  of  the  customary.  Indeed,  there  are 
certain  obscure  cases  of  ectopic  gestation,  those  for  instance  where  expe- 
rienced observers  have  diagnosticated  ovarian  cyst  and  normal  pregnancy, 
where  apparently  nothing  short  of  the  uterine  sound  will  make  the 
differential  diagnosis — even  anesthesia  fails  to  help  us.  It  is  here,  we 
believe,  that  the  absence  of  intermittent  uterine  contractions  will  not 
only  give  us  the  courage,  but  justify  us  in  passing  the  sound.  All 
observers  are  agreed  that  this  rhythmical  action  of  the  uterus  is  peculiar 
to  this  organ  when  gravid,  and  to  nothing  else.  The  distended  bladder, 
and  sub-peritoneal  fibroids,  have  also  been  said  to  contract,  the  former 
by  Pajot  and  Tarnier,  the  latter  by  Piuard,  but  only  the  veriest  tyro 
would  mistake  either  of  these  conditions  for  gravidity.  These  remarks 
are  applicable  purely  to  abdominal  gestation.  In  the  interstitial  form, 
and  the  tubal,  we  will,  of  course,  obtain  contractions,  although  possibly 
not  rhythmic. — Ed.] 

When  the  cyst  ruptures,  the  symptoms  will  suggest  the  diagnosis,  [but 
then  diagnosis  may  be  of  no  use  to  save  the  mother. — Ed.]  These 
symptoms  are:  sudden  acute  pain,  syncope,  followed  shortly  by  signs 
of  internal  hemorrhage,  and  death  may  soon  close  the  scene. 

If  the  hemorrhage  is  less  profuse,  these  signs  become  less  marked, 
and  they  are  replaced  by  chills,  intense,  and  frequently  repeated,  and  by 
the  symptoms  of  acute  peritonitis.  Death  may  here  also  follow,  but  not 
so  rapidly. 

Cure  may,  however,  follow.  If  both  the  foetus  and  the  mother  have 
escaped  destruction,  gestation  may  go  on  to  term,  and  then  false  labor 
set  in.  This  labor  may  kill  the  woman.  If  she  resists,  she  may  live  a 
greater  or  less  time,  carrying-  the  foetal  tumor,  which,  in  its  turn^ 
undergoes  changes,  which  we  will  refer  to  shortly. 

Duration. — This  is  far  from  being  settled  for  all  the  varieties.  It  is 
readily  apparent  that  when  the  ovum  develops  in  the  tube  or  ovary,  and 
more  still  in  the  thickness  of  the  uterine  tissue,  there  is  a  limit  to  pos- 
sible distention,  and  pregnancy  thus  necessarily  is  interrupted,  or  con- 


368 


A    TREATISE    ON    OBSTETRICS. 


verted  into  tlie  abdominal  Variety.  In  the  latter,  however,  the  ovum  is 
contained  in  a  large  cavity  where  it  may  increase  freely.  Whence,  then, 
great  differences  in  the  duration  of  the  various  varieties. 

Those  of  least  duration  are  the  interstitial.  Earely  do  they  exceed 
the  fourth,  usually  they  end  at  the  third  month.  According  to  Hecker, 
of  26  cases: 

Pregnancy  lasted  4  weeks,     .         .         1  case. 
"  "     about  3  months,         2  cases. 

'•      3  months,  .       12      " 

"      4       "  .         3      " 

''  "      5       "  .1  case. 

In  7  cases,  the  duration  was  not  noted. 

"Next  come  the  tubal  pregnancies.  If  we  consider  together  the  45 
cases  mentioned  by  Hecker,  and  the  43  by  Cauwenberghe,  for  these  88 
cases  the  duration: 


4  to  5 

weeks  in 

4  to  6 

li 

6  to  7 

C( 

6  to  8 

ii 

FoT  2  months  in 

3 

4 

5 

6 

7 

9 

3 

17 
9 

13 
4 

17 
11 

4 
2 
2 
6 


cases. 


Total, 


88  cases. 


Of  the  4  cases  which  reached  term,  (3anwenberghe  considers  anthentic 
only  the  two  cases  of  Lamm  and  Ssobel  Schsiboff.  To  these  we  must, 
however,  add  those  of  Haussner,  of  Eosshirt,  of  Saxtorph. 

These  cases  are  all  doubted  by  Stoltz,  who  contends  that  the  tube, 
distended  by  the  product  of  conception,  must  always  rupture  in  the 
early  months  of  pregnancy.  Neither  can  he  grant  the  so-called  second- 
ary gestations,  where  the  ovum  becoming  free  through  rupture  of  the 
tube,  continues  to  develop  in  the  abdominal  cavity  and  the  sub-peritoneal 
cellular  tissue. 

Ovarian  pregnancies  last  a  little  longer.  The  majority  extend  beyond 
the  third  month,  but  those  passing  as  far  as  the  seventh,  eighth,  and 
ninth  month,  are  nearly  as  rare  as  the  tubal  beyond  the  fifth  month. 
Thus  Cauwenberghe  in  39  cases  found: 


From  3  to  8  weeks, 
2  months, 
3 
4 


From  5  months, 
6 

9        " 


EXTRA-UTERINE   PREGNANCY.  369 

The  variety  in  which  duration  is  the  longest  is  the  abdominal.  Here, 
however,  a  distinction  must  be  made.  Shall  we  consider  as  pregnancy, 
those  cases  only  where  the  fcBtus  continues  to  live,  or  should  we  include 
those  cases  where,  after  death,  the  foetus  has  remained  years  in  the 
abdomen  of  the  mother?  We  contend  for  the  latter,  because  as  long  as 
the  foetus  is  in  the  abdomen,  it  is  liable  to  changes  which  inay  com- 
promise the  mother's  life,  or  call  for  surgical  aid.  We  cite  below  the 
table  which  De  Smedt  has  compiled.     It  concerns  185  cases. 


Duration  was 

15  days, 

1 

3ase. 

For  20  3 

•ears 

2  cases. 

3  weeks. 

1 

(( 

22 

1  case. 

1  to  2  months, 

18 

cases. 

25 

1     " 

I-5-  to  2^  months, 

4 

ce 

26 

3  cases. 

3  months, 

5 

ce 

28 

3     " 

3  to  5  months, 

22 

C  i 

30 

6     " 

6  to  8 

15 

a 

33 

3     " 

9 

18 

c : 

35 

1  case. 

10  mos.  to  1  year. 

6 

c: 

39 

1     " 

1  to    2  years. 

24 

a 

40 

2  cases. 

2  to    3    " 

10 

ic 

46 

4     '' 

4  to  10    " 

23 

c  1 

47 

2     " 

For  11  years. 

1 

case. 

50 

2     " 

15    " 

4 

cases. 

54 

1  case. 

16    " 

2 

li 

Indeed  the  duration  of  this  variety  of  gestation,  once  the  foetus  has 
passed  term,  and  the  woman  has  resisted  the  effects  of  the  false  labor 
wherein  the  foetus  was  killed,  is  purely  subordinate  to  the  changes  the 
foetus  undergoes,  to  their  nature,  their  progress,  and  the  ability  of  the 
female  organism  to  resist  them.  In  this  respect  nothing  is  more  varia- 
ble, for  traumatic  causes  may  at  any  time  Join  hands  with  the  foetal 
changes,  hasten  their  progress,  and  thus  determine  spontaneous  expul- 
sion, or  call  for  surgical  interference,  at  any  unexpected  moment. 

Termination. — Although,  in  the  majority  of  instances,  extra-uterine 
gestation  terminates  with  the  death  of  the  foetus  or  immediately  after, 
yet  often  the  woman  is  able  to  survive  the  grave  dangers  surrounding 
her  at  this  period.  She  may  rally,  keeping  her  babe  in  the  depths  of 
her  abdominal  cavity,  and  enjoy  relative  health  until  her  death,  which 
may  be  due  to  some  action  of  this  foreign  body,  or  else  to  causes  aside 
from  it.  We  may,  therefore,  from  the  present  standpoint,  divide  ectopic 
gestation  into  two  categories.  Where  the  pregnancy  ends  during  the  course 
of  gestation,  or  at  the  term  of  complete  foetal  development,  before  or 
Immediately  after  its  death,  instances  of  what  Cauwenberghe  has  called 
recent  pregnancies;  and  where  the  pregnancy  ends  only  after  a  variable 
interval,  after  a  longer  or  shorter  stay  of  the  foetus,  which  has  become 
Vol.  II.— 24 


370  A   TEEATISE   ON    OBSTETKICS. 

a  foreign  body,  in  the  body  of  the  mother,  instances  of  ancient  pregnan- 
cies, according  to  the  same  authority. 

De  Schmedt  prefers  the  following  divisions:  1.  The  cyst  ruptures  at 
a  variable  period  of  pregnancy,  and  this  rupture  entails  hemorrhage  fatal 
to  foetus  and  mother.  2.  The  foetus  continues  to  develop  and  is  subject 
to  the  modifications  which  we  have  already  considered.  3.  The  foetus 
determines  in  the  neighboring  organs  a  more  or  less  acute  inflammatory 
process,  and  is  eliminated  through  various  channels.  This  division  .only 
differs  from' the  former  in  that  it  makes  a  special  class  of  the  cases  where 
the  foetus  undergoes  retrograde  changes.  Now  it  is  precisely  these 
changes  which,  according  to  their  nature,  determine  complications,  or 
are  not  perceived. 

We  will  follow  the  first  classification. 

1st.  Recent  Preg^iancies. — A.  Rupture  of  the  Cyst. — This  rupture, 
which  is  the  rule  in  certain  varieties  of  ectopic  gestation,  may  not  occur 
at  all  in  others;  and  although  extremely  grave,  it  ,is  not  always  fatal, 
since  of  232  cases,  Cauwenberghe  only  found  71  where  the  women  died. 
This  rupture  is  usually  sudden,  and  occurs  the  earlier  in  gestation  where 
the  sac  is  interstitial,  tubal,  or  ovarian.  In  abdominal  gestation,  it  rare- 
ly happens  before  term,  at  the  time  of  the  false  labor.  The  consequences 
are  usually  fatal  to  mother  and  to  child,  although  not  always  so,  as 
witness  the  case  of  Scholler,  Mayer,  Wegscheider,  Campbell,  Virchow, 
and  others. 

Accompanied  by  hemorrhage,  which  Bernutz  and  Goupil  say  proceeds 
from  the  dilated  ovarian  veins,  from  the  tube,  from  the  ovary,  from  the 
cyst,  it  determines,  at  times,  such  shock  that  this  alone  may  cause  death. 
Usually,  however,  it  is  the  profuseness  of  the  hemorrhage,  and  the  com- 
plications, which  induce  the  fatal  end.  Again,  the  organism  is  not  so 
deeply  affected,  and  the  pregnancy  continues,  the  foetus  as  well  having 
escaped  destruction.  Further  still,  it  causes  the  death  of  the  foetus,  and, 
according  as  this  remains  in  the  sac,  or  escapes  into  the  peritoneal  cav- 
ity, we  may  witness  new  complications.  The  gestation,  in  either  event, 
becomes  ancient,  through  the  formation  of  a  new  sac,  and  this  we  con- 
sider further  on. 

B.  Without  Rupture  of  the  Cyst. — When  this  does  not  occur,  gestation 
may  end  in  three  ways: 

1st.  False  labor  sets  in,  usually  at  term,  it  ceases  shortly,  and  the 
woman,  whether  the  child  is  alive  or  not,  recovers  relative  health;  2. 
The  organic  troubles  which  accompany  this  abnormal  pregnancy,  instead 
of  diminishing,  increase,  and  the  woman,  worn  out,  dies  of  marasmus; 
3d.  The  presence  of  the  cyst  amongst  the  abdominal  viscera,  sets  up 
chronic  peritonitis,  and  the  woman  dies  from  inability  to  withstand 
these  repeated  and  prolonged  shocks. 

If  we  examine  the  reported  instances  of  each  variety  separately,  we 


EXTRA-UTERINE   PREGNANCY. 


find  that,  for  the  interstitial  variety,  of  the  2G  cases  of  Hecker,  all  ter- 
minated fatally  from  rupture  of  the  cyst.  For  the  tubal  variety,  of  46 
cases,  28  died  from  rupture,  1  from  rupture  of  a  vein,  13  passed  into  the 
category  of  old  pregnancies,  2  ended  in  cure,  2  through  expulsion  of 
tlie  foetus  through  the  uterus. 

For  the  abdominal  variety,  of  128  cases  we  find: 


Transferred  into  ancient  pregnancy, 
Abdominal  section,  and  one  case  by  rectal  section, 
Elytrotomy,  1  case  through  rupture  of  the  vagina, 
Eupture  of  cyst,  ...... 

Separation  of  placenta,  fatal  hemorrhage,     . 
Death  at  term,       ....... 

Peritonitis  and  cyst  rupture,  .... 

Marasmus,  a  little  before  term,       .         .         ,         . 

Peritonitis  consecutive  to  rupture. 

Acute  peritonitis,  ....,„ 

Chronic        "  ..,,,., 

Metrorrhagia  at  term,    .         .         .         .         =         . 

Osteomalacia,         ....... 

Ascites,  ........ 


85 
11 
6 
7 
1 
5 
3 
3 
2 
1 
1 
1 
1 
1 


Of  the  ovarian  cases:  Of  44,  19  died  from  rupture  of  the  cyst;  17  were 
transformed  into  the  ancient  pregnancy  category;  2  died  of  peritonitis 
without  cyst  rupture;  1  case  of  rupture  of  cyst,  consecutive  abdominal 
pregnancy,  fatal  chronic  peritonitis;  1  case  of  retention  of  urine,  death; 
1  of  fatal  metrorrhagia;  1  case  transformed  into  abdominal  pregnancy, 
and  went  to  term;  1  case,  gastrotomy,  success  for  mother  and  child;  1 
case,  hanging  of  the  mother  during  pregnancy.  ' 

Referring  back  to  the  abdominal  variety,  the  85  cases,  transformed  into 
ancient  gestation,  are  decomposed  as  follows: 

In  22,  mummification,  etc.,  and  cure. 

In    3,  death,  hectic  fever,  no  cyst  rupture. 

In    3,  ascites,  death,  foetus  dead. 

In  57,  elimination  by  vagina,  the  abdominal  walls,  the  rectum,  the 

the  bladder,  and  33  recovered. 
Total  number  of  recoveries — 55  cases. 

2.  Ancient  Pregnancies. — These  are  characterized  by  the  presence  of 
a  dead  foetus  in  the  midst  of  the  abdominal  organs,  surrounded  by  a  cyst 
more  or  less  isolated  from  the  viscera,  or  forming  adhesions  to  them. 
Mattel  has  collected  100  cases,  and  he  thus  classifies  them  according  to 
termination: 


By  mummification. 

Without  external  opening, 

Elimination  through  abdominal  walls, 
"  "       vagina, 

"  "       bladder, 

**  ^'       rectum. 


12  cases 

2 
38 

7 

8 
30 


372 


A   TEEATISE    O'N   OBSTETRICSc 


This  table  accords  with  that  of   Cauwenberghe,  who,  for  180  cases, 
resumes  as  follows  : 


23 
1 

14 
3 


A.  Women  dying  from  cause  not  depending  on  the  preg- 

nancy, after  having  carried  the  fcetal  debris  for  a 
number  of  years,  ...... 

B.  Women  dying  from  complications  due  to  the  presence 

of  the  cyst,  without  external  opening  : 
1st.    From  inflammation,         .         .         .         .         .9 

2d.         "     septic  fever,  .....       1 

3d.     Opening  into  peritoneum,        ....       2 

4th.    Hectic,  and  marasmus,  ....       4 

5th.    Ascites,  .......       5 

0.     Opening  of  the  cyst  through  anterior  abdominal  walls 
1st.   Spontaneous  opening,  cure,     .         .         .         .  ~ 

"  '-'       death,  .... 

2d.    Surgical  extraction,  cure,         .... 

death,      .... 

3d.    Gastrotomy,  cure,  ..... 

death, 

D.  Opening  of  cyst  into  bladder,  extraction  of  bones 

Cure,        ...... 

Death,      ...... 

E.  Foetus  eliminated  by  vagina  : 
1st.  Spontaneous  expulsion,  cure, 

death, 
2d.  Operative  extraction,  cure,  .         .         .         o 

F.  Opening  into  intestines,  elimination  of  foetus  in  whole 

or  in  part,  with  and  without  interference  : 

1st.  Cure,  ......         18 

2d.  Death,  .         .         .         .         .         .30 

Total, 


42 


V     21 


y      53 


10 


48 


180  cases 


The  above  table  gives,  in  general,  the  manner  of  issue  of  ectopic 
gestations,  but  in  a  number  of  individual  instances,  death  occurred 
under  peculiar  circumstances:  Richets'  case,  where  a  woman  on  the 
road  to  recovery,  was  seized  with  epidemic  puerperal  fever;  Depaul's 
case,  which  died  of  cholera;  Depaul's  second  case,  where  the  uterine 
sound  pierced  the  uterus,  and  resulted  in  fatal  peritonitis;  two  other 
cases  of  Depaul  and  Boinet,  where  the  women  died  of  hemorrhage 
resulting  from  separation  of  the  placenta;  a  case  of  Gruichard  d 'Angers, 
where  the  sound  caused  peritonitis;  Spiegelberg's  case,  where  both 
mother  and  foetus  died  of  eclampsia;  Wurm's  case,  where  the  woman 
died  with  symptoms  of  intestinal  obstruction. 

Diagnosis. — The  diagnosis  is  divisible  into  two  categories:  1st.  We 
must  establish  the  fact  that  we  are  dealing  with  pregnancy,  and  that  it 
is  ectopic.     2d.  Establish  the  variety  of  ectopic  gestation  present. 

It  would  seem  as  though,  from  an  enumeration  of  the  symptoms,  the 
diagnosis  ought  to  be  easy,  nevertheless  ectopic  gestation  has  often  been 


EXTRA-UTERINE   PREGNANCY.  373 

overlooked  and  only  recognized  post-mortem.  In  the  absence  of  the 
foetal  heart  and  the  active  movements  of  the  foetus,  the  diagnosis  of 
pregnancy  itself  is  frequently  difficult,  the  greater  the  difficulty  when 
the  pregnancy  is  ectopic.  We  agree  with  Depaul,  however,  that  we 
will  usually  reach  the  diagnosis,  by  remembering  the  signs  furnished  by 
palpation  and  the  touch.  But  what  number  of  errors  committed  since 
the  case  of  Huguier  (uterine  pregnancy  mistaken  for  ectopic),  to  that  of 
Dubou6,  where  first  pregnancy  in  the  uterus,  then  ectopic  gestation,  then 
the  use  of  the  sound,  and  again  uterine  pregnancy,  were  diagnosticated! 
What  the  result  in  a  case  like  Depaul's,  where  hydramion  complicated? 
What,  where  both  intra-  and  extra-uterine  pregnancy  concomitantly 
exist?    What,  in  case  of  ovarian  cyst,  and  ectopic  gestation  (Gueniot)? 

At  the  sixth  month,  in  the  presence  of  the  foetal  heart,  and  the  foetal 
movements,  felt  often  just  under  the  surface,  in  the  presence,  further 
of  the  form,  volume,  and  situation  of  the  tumor,  the  diagnosis  may  be 
easy,  but  later  the  difficulties  may  increase.  If  the  case  is  first  seen 
after  foetal  death,  the  signs  of  pregnancy  are  obscure.  The  uterus  has 
retrograded,  and  the  tumor  has  changed  greatly.  The  absence  of  history, 
further  still,  increases  the  difficulty,  and  it  is  only  by  careful  elimination 
that  we  may  form  an  opinion  as  to  the  nature  of  the  tumor. 

[The  errors  in  diagnosis  committed  by  various  authorities  are  here 
cited.  They  might  be  increased  by  a  long  list  taken  from  the  clinical 
records  of  this  country.  Sufficient  the  statement  that  the  following 
amongst  other  mistakes  have  been  made:  uterine  pregnancy  (and  the 
reverse  has  occurred);  retroversion  of  the  gravid  uterus;  pelvic  hemato- 
cele; multilocular  cyst  of  the  ovary;  anteversion  of  the  uterus;  fibro- 
cystic tumor  of  the  uterus,  etc. — Ed.] 

As  for  the  differential  diagnosis  between  the  varieties  of  ectopic 
gestation,  there  is  only  question  during  the  early  months,  for  later  it  is 
rare  to  meet  with  anything  but  abdominal  pregnancy. 

I7i  Tubal  Pregnancy,  the  pain  is  deep,  dull,  fixed;  the  tumor  is  mov- 
able, the  uterus  is  to  the  side  opposed  to  the  tumor  and  adhering  to  it. 
[On  the  contrary,  in  many  of  the  reported  cases  of  tubal  pregnancy  in 
this  country,  the  tube  has  been  detected  behind  the  uterus,  and  con- 
sequently not  so  very  movable. — Ed.]  According  to  Heim,  it  is  in  this 
variety  that  the  pain  is  most  characteristic. 

In  Ovarian  Pregnancy,  pain  is  still  a  factor,  but  the  tumor  is  further 
from  the  uterus  and  consequently  more  movable. 

In  Ah dommal  Pregnancy ,  the  uterus  is  less  developed,  it  may  be  more 
readily  isolated  from  the  tumor.  The  foetal  movements  are  more  easily 
felt.  At  times  the  foetal  parts  are  felt  under  the  skin,  as  it  were.  The 
tumor  is  larger,  and  has  attained  greater  development,  [intermittent 
rhythmic  contractions  cannot  be  evoked. — Ed.] 

Such  are  the  diagnostic  signs  as  stated  by  the  authorities.     They  are 


374  A    TEEATISE    ON   OBSTETEICS. 

very  Yague,  and  if  it  is  possible,  at  times,  to  diagnosticate  ectopic 
gestation  in  the  early  months,  it  is  usnally  not  possible  to  state  its 
variety. 

[Nevertheless,  if,  in  the  early  months,  a  woman  has  missed  one  period, 
has  had  irregular  discharges  preceded  by  cramp-like  pain  in  the  abdomen, 
if,  further,  certain  of  the  rational  signs  (nausea,  etc.,)  of  pregnancy  are 
complained  of,  and  on  careful  examination  an  oval-shaped  tumor  is 
found  posterior  or  to  one  side  of  the  uterus,  we  may  always  think  with 
a  great  degree  of  certainty  of  tubal  pregnancy.  Examination  by  the 
rectum  under  anesthesia  will  assist  our  diagnosis,  and  it  is  peculiarly 
necessary  to  reach  a  diagnosis  of  this  form  of  gestation  early,  for,  as  we 
point  out  further  on,  we  possess  a  certain  means  of  arresting  the  gesta- 
tion before  the  mother's  life  is  imperiled  by  rupture,  and  this  means 
further  is  of  absolutely  no  danger  to  her.  In  this  country  'he  weight  of 
opinion  certainly  is  that  tubal  pregnancy  may  ordinarily  be  diagnosti- 
cated early,  and  of  late  years  the  number  of  instances  where  this  has 
been  done  have  greatly  increased. — Ed.] 

Pi'ognosis. — This  is  always  ominous,  both  to  the  child  and  the  mother, 
either  in  the  present,  or  in  the  future. 

Treatment. — Authorities  are  in  agreement  as  to  there  being  two 
divisions  of  the  cases  in  regard  to  treatment:  1st.  The  woman  is  in  the 
fourth  to  the  fifth  month  of  pregnancy;  2d.  she  has  passed  this  period, 
she  is  near  term,  or  has  passed  it. 

Since,  in  the  early  months,  it  is  nearly  impossible  to  say  with  what 
variety  we  are  dealing,  we  are  authorized,  says  Keller,  to  consider  it 
tubal,  since  this  is  the  one  which  most  endangers  the  mother's  life. 
Since  now,  tubal  pregnancy  nearly  always  results  in  the  death  of  the 
mother,  we  must  stop  the  gestation,  as  soon  as  it  is  recognized.  We  must, 
then,  determine  the  easiest  and  safest  method  of  accomplishing  this. 

Van  Eitgen  has  advised  the  employment  of  meagre  diet,  and  to  weaken 
the  mother  further  by  administering  daily  purgative  salines  and  ergot. 
But  such  treatment  whilst  likely  to  diminish  the  size  of  the  foetus,  will 
not  kill  it,  and  therefore  does  not  produce  the  desired  result.  As  for 
ergot  its  action  is  nil.  More  radical  methods  were  then  thought  of, 
and  Heim,  and  Osiander,  even  counseled  extirpation  by  the  knife.  But 
this  means  has  never  been  put  into  practice  before  rupture.  [After 
rupture  it  has  a  number  of  times,  by  Lawson  Tait,  in  particular,  and  with 
success.  In  less  than  three  years  he  has  performed  laparotomy  in  case  of 
ruptured  tubal  gestation,  in  21  cases,  with  success  in  20.  He  advocates, 
also,  operating  in  these  cases,  even  as  he  would  for  distention  of  the 
tube  by  serum,  pus,  or  blood.  He  does  not  trouble  himself  about 
exact  diagnosis,  indeed  he  has  lately  stated  his  belief  that  it  was 
impossible  to  reach  an  early  diagnosis  of  tubal  pregnancy,  and  herein 
he   is  unquestionably   in   error.     He  would  operate  because  the  exami- 


EXTRA-UTERINE    PREGNANCY.  375 

nation  reveals  a  tumor,  probably  tubal,  and  because  the  symptoms 
complained  of  can  be  traced  to  the  tubal  enlargement.  His  principle 
is  correct,  for  it  is  as  easy  a  matter  to  remove  a  tube  distended  by 
a  product  of  conception,  as  one  distended  by  pus  or  blood.  But, 
as  we  will  sec,  his  advice  is  not  justifiable,  except  in  the  presence 
of  rupture,  because  we  possess  a  less  radical,  less  dangerous,  and  just  as 
eifective  means  of  disposing  of  tubal  pregnancy. — Ed.]  There  are  other 
methods  which  seem  less  dangerous,  although  just  as  eifective.  For 
instance,  puncture  of  the  foetal  cyst,  as  proposed  by  Scanzoni.  Martin 
resorted  to  it  through  the  abdominal  walls  (abd.  preg.  of  2^  months),  the 
patient  died.  Braxton-Hicks,  and  Simpson  punctured  through  the  va- 
gina. The  patients  also  died.  Greenlagh  was  more  successful  in  a  case 
at  two  months.  Depaul  asks,  if  in  these  instances  it  was  really  ectopic 
gestation,  for  we  have  seen  how  difficult  the  diagnosis  is,  if  not  impossi- 
ble, at  such  an  early  stage  of  pregnancy. 

Joulin  proposed  to  kill  the  foetus  by  the  injection  into  the  sac,  of  mor- 
phia, or  strychnia,  in  sufficient  quantity  to  kill  the  foetus,  but  not  sufficient 
to  be  toxic  to  the  mother.  Friedreich  resorted  to  this  method  a  year 
after  with  perfect  success.  Koeberle  also  obtained  a  good  result.  But 
in  Fournier's  case,  as  recorded  by  Depaul,  the  injection  caused  inflam- 
matory symptoms  in  the  mother,  requiring  laparotomy,  and  ending  in 
the  maternal  death. 

Paul  Dubois  recommended  electricity,  and  Bachetti  thus  endeavored 
to  kill  the  foetus,  and  the  mother  recovered.  Braxton-Hicks  failed  by 
this  method:  Duchenne,  of  Boulogne,  rejected  it. 

Finally,  Dr.  Malin  proposed  compression  of  the  tumor  between  sand- 
bags, but  this  has  never  been  tried. 

[The  method,  above  all  others,  applicable  to  tubal  pregnancy,  is  elec- 
tricity. This  may  fairly  be  called  an  American  method,  because,  up  to 
the  present,  with  but  one  or  two  exceptions,  it  has  been  practised  only 
here,  but  with  such  uniformly  happy  results  as  to  lead  us  to  reject  every 
other  proposed  means  of  treating  tubal  pregnancy  when  diagnosticated 
before  rupture. 

Puncture  of  the  sac  has  been  rejected  by  American  authorities  because 
of  its  nearly  uniformly  fatal  results.  Braxton-Hicks,  Goodell,  Simpson, 
E.  Martin,  Gallard,  Depaul,  Wetzel,  and  others,  have  placed  on  record 
cases  where,  in  consequence  of  the  method,  the  mother  died.  The 
method,  further,  if  not  fatal  to  the  mother,  is  by  no  means  certain  as 
regards  death  of  the  child. 

Injection  of  the  sac  has  been  successful  in  a  number  of  instances,  but, 
as  proved  by  Friedreich's  second  case,  the  method  is  tedious,  as  well  as 
dangerous.  Lately  another  case  has  been  recorded  by  Eennert,  making 
the  fourth  treated  by  this  method,  where  the  mother  recovered,  the 


376  A  TREATISE    ON    OBSTETEICS. 

foetus,  in  the  fifth  month,  was  killed,  and  where,  notwithstanding  most 
careful  antiseptic  precautions  the  mother  narrowly  escaped  death. 

Extirpation  by  the  vagina,  attempted  once  successfully  by  Thomas,  has 
been  also  attempted  by  the  late  Albert  H.  Smith,  who  opened  with  the 
cautery,  the  patient  dying  of  gangrene  of  the  peritoneum;  by  Battey,  of 
Georgia,  with  the  bistoury,  the  patient  dying  of  exhaustion.  This  meth- 
od, therefore,  may  fairly  be  called  dangerous,  and  be  rejected. 

Laparotomy  is  strongly  advocated,  as  we  have  stated  above,  by  Lawson 
Tait,  but  prior  to  rupture  of  the  tube,  no  American  authority  will  herein 
agree  with  him.  To  mention  only  one,  and  him  on  account  of  his  ex- 
ceptionally large  experience  with  these  cases,  Thomas,  of  New  York,  says, 
"the  growing  triumphs  of  abdominal  surgery  are  apt  to  lead  to  the  con- 
viction that  laparotomy  should,  as  a  rule,  be  the  procedure  of  election 
in  these  cases.  From  this  view  I  unqualifiedly  dissent,"  for  the  reason 
that  he,  in  conjunction  with  Lusk,  Munde,  Goodell,  Garrigues,  Eock- 
well,  and  a  host  of  other  distinguished  gentlemen,  know  of  a  safer  and 
just  as  effective  method,  which  we  now  consider  as  the  method  ^jar  ex^ 
celUnce  in  the  treatment  of  tubal  pregnancy,  prior  to  the  fourth,  per- 
haps the  fifth  month  of  gestation — electricity. 

Either  the  galvanic  or  Faradic  current,  may  be  used.  The  current 
from  a  twenty -cell  galvanic,  or  from  a  pocket  Gaiffe  Faradic,  is  of 
sufiicient  strength.  One  electrode  is  placed  over  the  abdomen,  and 
the  other  in  contact  with  the  tumor  per  vaginam,  or  pei'  rectum.  In 
case  of  the  galvanic  current,  it  should  be  rapidly  interrupted.  This 
current  should  never  be  too  strong,  else,  as  in  the  case  recorded  by 
Munde,  shock  may  result.  Electricity  should  be  used  every  other  day 
until  the  tumor  has  markedly  diminished  in  size.  The  death  of  the 
foetus  is  known  by  the  cessation  of  the  growth  of  the  tumor,  and  of 
whatever  rational,  or  physical  signs  of  pregnancy  may  be  present.  This 
method,  when  compared  with  all  the  others,  is  seen  to  be  absolutely  free 
from  danger:  it  has  proved  successful  in  every  case  where  it  has  been 
tried.  Thomas  himself  has  had  over  six — eight? — and  all  the  cases 
included  amount  nearly  to  forty.  Munde,  in  the  early  part  of  this  year, 
gives  the  figures  as  about  thirty-five,  A  further  advantage  of  this 
method  is  that,  in  case  of  an  error  in  diagnosis,  it  can  do  no  possible 
harm.  The  method  is  applicable  to  every  form  of  Ectopic  gestation 
prior  to  the  middle  or  end  of  the  fourth  month,  and  prior  to  rupture  of 
the  cyst.  It  has  been  claimed  against  the  method  that  it  is  likely  to  cause 
rupture  of  the  cyst.  Our  best  answer  to  this  objection  is  that  rupture 
has  never  been  produced. 

It  is  in  place  to  mention  here  the  fact  that  in  case  of  interstitial  preg- 
nancy, the  effect  of  the  electricity  may  be  to  convert  this  form  of  ectopic 
gestation  into  uterine,  by  driving  the  foetus  from  its  sac  into  the  uter-, 
us.     Such  instances  have  been  reported  by  Munde  and  others,  and  Gar- 


EXTRA-UTERINE    PREGNANCY.  377 

rigues  has  recently  recorded  a  case  where  the  foetus  went  to  term  in  the 
uterus,  after  having  been  expelled  from,  its  interstitial  sac. 

Up  to  the  present,  the  use  of  electricity  in  early  ectopic  gestation 
has  been  almost  entirely  limited  to  the  United  States.  In  the  old  world, 
men's  minds  are  slow  to  receive  methods  practiced  in  this  new  world. 
It  is  safe  to  predict,  however,  that  electricity  will  yet  become  the  only 
method  of  treatment  of  ectopic  gestation  prior  to  rupture  of  the  cyst, 
and  that  through  this  means  the  dreadful  mortality  from  gestation  of  this 
nature  will  be  reduced  by  fully  three-quarters. — Ed.] 

The  means  which  we  have  outlined  are  rational,  but  the  difficulties 
in  application  are  great,  and  the  greatest  of  all  is  to  reach  certain  diag- 
nosis in  the  early  months. 

This  diagnosis,  we  have  seen,  is  reached  often  only  at  rupture  of  the  cyst, 
and  when  the  symptoms  of  internal  hemorrhage  are  marked.  What 
must  then  be  the  course  of  action?  Must  we,  as  Depaul  counsels,  limit 
our  efforts  to  fightiag  the  symptoms  of  hemorrhage,  and  of  supervening 
inflammation?  or,  as  Keller  counsels,  resort  to  gastrotomy,  and  extract 
the  sac  and  foetus?  Ctoltz  admits  the  justifiability  of  extirpation  only 
when  the  tumor  is  movable;  when  the  sac  is  adherent  to  the  peritoneum, 
to  the  intestines,  the  bladder,  the  uterus,  etc.,  it  would  be  folly  to  touch  it. 

Depaul,  in  view  of  the  fact  that  symptoms  of  internal  hemorrhage, 
and  of  peritonitis,  may  occur  aside  from  ectopic  gestation,  and  that  we 
have  no  means  of  knowing  the  exact  cause,  is  opposed  to  all  surgical 
measures.  Keller,  on  the  other  hand,  backed  up  by  the  weight  of 
authority  of  Velpeau,  Kiwisch,  Duparcque,  and  Keoberle,  favors  opera- 
tion. We  must,  he  says,  check  the  hemorrhage,  remove  the  cause, 
cleanse  the  peritoneal  cavity. 

Cauwenberghe  agrees  with  Depaul,  and  so  do  we.  Practise,  indeed, 
one  of  the  gravest  of  all  operations,  at  the  time  when  the  woman  is  in 
deep  shock!  The  time  required  to  open  the  abdomen,  to  search  for  the 
source  of  the  hemorrhage,  to  apply  the  ligatures,  to  cleanse  the  peri- 
toneum, might  better  be  given  to  compression  of  the  aoria,  and  the 
dangers  to  which  the  woman  is  exposed  during  the  operation,  in  fact 
and  in  consequence,  are  greater  than  those  for  which  it  is  attempted, 
since  numerous  cases  prove  that  the  woman  may  rally  from  the  symp- 
toms, and  the  infant  continue  to  live  in  the  new  locality  where  rupture 
places  it. 

[Although  rupture  does  not  always  mean  the  death  of  the  mother,  it 
may,  as  reported  cases  prove.  The  surgery  of  to-day  is  tending  to  the 
belief  that,  in  the  presence  of  symptoms  of  internal  abdominal  hemor- 
rhage, immediate  laparotomy  is  not  only  justifiable,  but  the  proper  duty 
of  the  attendant  as  well.  It  is  an  emergency,  above  all  others,  requiring 
nerve,  but  it  is  one  from  which  we  may  no  longer  shrink.  Over  twenty 
years  ago,  an  American,  Stephen  Rogers,  advocated  immediate  laparot- 


378  ^   TEEATISE    ON    OBSTETRICS. 

omy  in  case  of  tubal  rupture;  Veit,  of  Berlin,  performed  it;  Thomas, 
of  New  York,  would  have  done  so,  a  few  years  past,  had  he  not  been 
overruled;  Briddon,  of  JSTew  York,  in  1883,  performed  it,  the  patient 
rallied  for  forty-seven  hours,  and  then  died  of  shock — in  this  case,  how- 
ever, laparotomy  was  not  resorted  to  on  the  first  symptoms  of  rupture; 
Tait,  of  Bermingham,  has  repeatedly  operated,  with  almost  uniform 
success.  Other  instances  might  be  mentioned,*  but  our  point  here  is 
simply  to  show  that  laparotomy  is  justifiable,  and  likely  to  save  the 
mother  if  performed  in  time.  We  have  no  desire  to  dogmatize;  we 
simply  aim  at  pointing  out  the  drift  of  surgical  opinion.  The  operation 
itself,  whether  the  sac  be  adherent  or  not,  is  only  a  little  more  difficult  than 
extirpation  of  the  adherent  pyosalpinx,  or  diseased  ovaries ,  on  account 
of  the  hemorrhage,  the  amount  of  blood  in  the  abdominal  cavity.  A 
specimen  recently  presented  by  Munde  to  the  New  York  Obstetrical 
Society  proved  conclusively  that,  however  easy  the  removal  of  the  cyst 
and  foetus  might  be,  the  checking  of  hemorrhage  is  another  matter.  In 
the  specimen  referred  to  there  existed  a  rent  in  the  posterior  wall  of  the 
uterus,  where  the  tube  had  been  adherent.  Thi^rent  was  iii  part  the 
source  of  the  hemorrhage,  and  had  an  operation  been  attempted  it  could 
only  have  been  successfully  ended  by  hysterectomy.  It  is  well  to 
remember,  therefore,  that  this  latter  operation  may  be  called  for. — Ed.] 

After  the  fourth  to  the  fifth  month  the  conditions  are  no  longer  the 
same. 

The  diagnosis  may  be  assured,  and  we  are  dealing,  nearly  always,  with 
the  abdominal  variety.  It  has  been  proved  that,  m  these  cases,  the 
foetus  may  go  to  term,  and  live.  Although  the  physician  ought  to 
succor  the  mother,  his  duty  as  well  is,  as  far  as  possible,  to  save  the 
child.  Gastrotomy  best  subserves  these  two  indications.  When  should 
it  be  performed? 

Whilst  Zang  and  Velpeau  have  proposed  to  extract  the  foetus  as  soon 
as  it  is  viable,  in  order  to  avoid  the  complications  which  may  occur 
between  seven  and  nine  months,  Depaul  favors  a  little  longer  waiting, 
in  the  interests  of  the  child.  But  he  would  not  wait  "till  the  ninth 
month.  Although  certain  women  have  gone  to  term,  and  passed  it, 
before  the  phenomena  due  to  foetal  death  have  manifested  themselves, 
I  should  fear  whilst  waiting  for  nature's  danger  signal,  to  lose  altogether 
the  advantages  accruing  from  hastier  action.  We  need  simply  to  be  in 
no  doubt  as  to  the  infant's  viability.  This,  for  ectopic  gestation,  must 
be  placed  at  the  end  of  the  eighth  or  the  beginning  of  the  ninth  month, 
for  the  foetus  does  not  develop  as  quickly  as  in  uterine  gestation.     I 


*  As  these  pages  are  passing  through  the  press,  we  are  able  to  record  the  first  successful  primary 
laparotomy  in  case  of  ruptured  tubal  cypt  ever  performed  in  this  country.  The  operator  was 
Johnstone  of  Kentucky,  and  the  case  is  recorded  in  the  New  York  Med.  Rec.  February  26,  1887. — Ed. 


EXTRA-UTEKIKE   PREGNANCY.  379 

■would  then  only  interfere  at  this  period,  except  where  labor  sets  in  earlier, 
and  at  a  stage  when  I  might  count  still  on  the  viability  of  the  infant." 

Keller  favors  waiting  for  the  pains.  Other  authorities  do  not  accept 
this  opinion;  Sabatier,  Siebold,  Gerdy,  amongst  others,  nearly  absolutely 
reject  it. 

[In  this  country,  Lusk  probably  states  the  prevalent  opinion.  "If  we 
accept  Parry's  statement  as  approximately  correct — that  in  499  cases  of 
extra-uterine  pregnancy,  including  174  of  ruptured  cyst,  the  mortality 
was  67.2.  per  cent. — it  is  evident  that  much  remains  to  be  done  in  the 
way  of  perfectiug  the  primary  operation  before  its  admissibility,  except 
under  desperate  conditions,  can  be  recognized.  In  ten  cases  reported  by 
Litzmann,  only  four  children  survived  the  third  day."  Thomas  says, 
"If  there  is  a  living  child  in  the  abdomen,  remove  it  at  the  end  of  the 
ninth  month.  The  life  of  the  child  should  be  saved  at  the  expense  of 
increased  risk  to  the  mother." — Ed.] 

The  capital  point,  however,  is  not  to  touch  the  placenta.  This  must 
be  left  to  be  eliminated,  when  the  maternal  blood  vessels  have  become 
obliterated.  The  chief  dangers  after  gastrotomy  at  term,  are  septicemia, 
secondary  hemorrhage,  and  peritonitis. 

The  following  cases  we  borrow  from  Keller:  1st.  Schreger,  1836, 
pregnancy  at  term,  mother  and  child  saved.  2d.  Heim,  child  saved, 
mother  died.  3.  Mattfeld,  child  saved,  mother  died  of  hemorrhage 
and  peritonitis.  4th.  Dr.  JST.,  child  living,  mother  died.  5th.  Lecluyse, 
mother  died  of  peritonitis,  child  a  little  after.  6th.  Sale,  uterine  and 
extra-uterine  pregnancy,  children  living,  mother  dead.  7th.  Muller, 
mother  and  child  living.  8th,  Eingen,  and  9th,  Gardien,  mothers  and 
children  living. 

Keller  cites  other  cases  where  gastrotomy  might  have  been  performed 
at  term,  since  the  child  did  not  die  till  after.  He  concludes  from  his 
observations:  Often,  in  abdominal  gestation,  the  condition  of  the 
mother,  at  term,  is  very  good.  2d.  Expectation  is  far  from  being  always 
favorable  to  the  mother,  and  often  complications  ensue  soon  after 
foetal  death.     He  therefore  favors  gastrotomy. 

In  certain  special  cases  it  has  been  proposed  to  substitute  vaginotomy 
for  gastrotomy.  Of  three  cases  of  the  kind,  in  the  first  the  mother  died 
in  a  few  days  of  acute  peritonitis,  in  the  second,  a  living  child,  although 
not  at  term,  was  extracted,  in  the  third,  the  success  was  complete  for 
mother  and  child. 

What  should  be  our  course  of  action,  if  we  only  see  the  woman  after 
foetal  death?  Depaul  counsels  expectancy.  If  the  pregnancy  has  reached 
term,  or  nearly,  he  would  only  interfere  in  case  of  symptoms  showing 
that  the  foreign  body  was  not  being  tolerated.  In  case  complications 
pointing  to  inflammation,  or  cyst  decomposition,  occur,  he  would  inter- 
fere at  once,  since  the  success  of  the  operation  depends  on  the  health. 


380 


A   TREATISE    ON"   OBSTETRICS. 


and  the  condition  of  the  woman.  When  term  has  been  passed,  and  the 
foetus  is  dead,  we  need  only  think  of  the  mother.  Now  the  formation 
of  a  lithopedion  is  rare,  and  sooner  or  later,  nature  attempts  the  elimina- 
tion of  the  foreign  body.  The  cyst  inflames,  and  the  gravest  compli- 
cations may  ensue.  The  cyst  may  open  through  the  abdominal  walls, 
rectum,  vagina,  bladder,  even  the  perineum,  as  two  cases  of  Pigeolet 
prove.  It  is  evident,  to  what  dangers  the  woman  is  exposed  during 
this  work  of  elimination:  peritonitis,  hemorrhage,  sepsis,  marasmus. 
Therefore  gastrotomy  is  indicated.  Conditions  differ  according  to 
whether  adhesions  are  present,  or  the  cyst  is  free.  Where  the  latter  is 
the  case,  it  has  been  proposed  to  cause  the  formation  of  adhesions  by 
practising  gastrotomy  by  means  of  caustics  instead  of  the  bistoury. 

We  append  the  operations  practiced  by  bistoury  and  caustic,  in  so  far 
as  we  have  been  able  to  collect  them: 

Gastrotomy  hy   the  Knife. 


Keller, 
Jessop, 
Eoss  Jordan, 
Lawson  Tait, 

13  recoveries. 
1  recovery. 
1 
1 

Keller, 

Depaul, 

Tarnier, 

Meadows, 

Scotfc, 

Haberly, 

Tait, 

Boinet, 

Total, 

5  deaths, 

2 

1  death. 

Total, 

16  recoveries. 

13  deaths, 

Rousseau, 

Beauvoisin, 

Duboue, 


Total, 


Gastrotomy  ly  Caustics. 


1  recovery. 
1 


3  recoveries. 


Depaul, 


1  death. 


[Meadows,  of  Loudon,  has  had  a  successful  case,  Thomas  three  suc- 
cessful, where  gastrotomy  was  performed  by  the  knife. 

It  is  gastrotomy  then,  and  not  vaginotomy  which  should  be  resorted  to, 
except  in  those  rare  instances  where  the  foetal  sac  bulges  in  the  vagina. 
All  authorities  are  agreed  on  this  point.  Tait,  Freund,  and  Thomas, 
and  others.  Further  the  same  point  is  proved  by  Parry's  statistics,  and 
also  by  those  of  Deschamps,  which  are  the  most  recent  we  have.  The 
following  table,  compiled  by  him,  is  of  interest,  as  showing  the  issue  in 
59  cases  which  went  beyond  term,  out  of  114,  reported  between  1875 
and  1880. 


EXTRA -UTERINE    PREGNANCY.  881 

In  11  cases  formation  of  lithopedion  or  encystment. 
In  19     "     opening  into  rectum  with  8  deaths. 
In    3     "  "  "     vagina      "     1  death. 

In    1  case         "  "     uterus      "     1       " 

In    5  cases       "        at  umbilicus    "     0      " 
In  18     "     secondary  laparotomy  "     4  deaths. 

To  quote  then  a  statement  made  by  us,  a  year  ago,  when  reporting 
a  case  of  abdominal  gestation  :  "When  nature  establishes  an  outlet  in 
the  abdominal  wall,  the  patient  is  more  likely  to  recover,  than  when 
she  establishes  an  outlet  elsewhere;  and  thus  she  endeavors  to  teach  us 
the  point  at  which  incision  should  by  preference  be  made," 

The  mortality  from  secondary  laparotomy  had,  in  1880,  been  lowered 
to  22.3  per  cent.  When  Parry  wrote  it  was  38,8  percent.  We  have 
a  right  to  expect  better  results  in  the  future,  especially  when  we  find 
Bandl  and  Lusk  advocating  the  secondary  operation,  as  soon  as  the 
maternal  blood  vessels  have  had  a  chance  to  shrivel,  instead  of  waiting, 
as  has  been  the  custom,  until  the  woman  is  in  the  grasp  of  sepsis,  or 
of  peritonitis.  Indeed,  with  electricity  for  the  early  months,  and  timely 
laparotomy  in  the  later,  ectopic  gestation  bids  fair  to  be  robbed  of  its 
terrors  and  murderous  results. — Ed.] 

Gastrotomy,  then,  in  ectopic  gestation,  should  receive  the  careful  con- 
sideration of  observers.  The  ever-increasing  betterment  of  the  results 
after  ovariotomy,  lead  us  to  hope  for  the  same  after  gastrotomy.  Every 
observer  should  publish  his  cases:  thus  alone  may  we  be  enabled  to  reach 
an  efEective  method  of  treatment. 


7 


